A pink frothy mess

My heart is failing and
Your fluid and my air

become together

A pink frothy mess.

I drown in your pink sea.

Acute pulmonary love edema.

Do you want to be the oxygen, or do you want to be the blood, or do you want to be oxygenated blood?

I wrote this poem before and put it here somewhere a few years ago, I just chopped it down a little bit. The lungs filled with water, and the crooked heart is my art above. I miss drawing, but I do not have the software corelDRAW anymore, so my days of being a fake artist are over. Besides my art work is not that great.

I can write fake love poems like the one above to go with fake art, but the thing is I better get studying. I test next Wednesday.

So the first time I experienced this acute pulmonary edema working on telemetry revealed some facts to me. I had learned about this in school probably, maybe not. What happened was that my patient during 0800 assessments appeared anxious, but was saturating fine according to the pulse ox and the blood pressure was high normal, although I noticed the diastolic seemed high, but not >1o0. His lungs sounded totally clear. He was a big guy sitting up with 3 pillows in the bed. He did not have massive edema or anything like that. I figured he would need some XANEX in the future.

Xanex is not what the patient needed. By the time 1200 assessments came around, the patient was labored, short of breath, with a respiratory rate around high 20s per minute. You see tissues all over the floor with ping tinged sputum, and wonder: Where the hell have I been for 4 hours?  The blood pressure was 200/110, and rales, tachycardia, and the patient was cool. The patient was desaturating to the 80s.  The patient was starving for air, you know that look in the eyes. That look from the patient, is like some kind of fear, that I do not want to ever feel. And then they want to talk and tell you about how they can’t breath, and we tell them, don’t talk, we already know, we are going to try to fix this right now.

I said, Uh-Oh this is not right. The work to breathe appeared so hard, people like that can not carry on with that workout forever. Ya know, the abdomen is swelling up and collapsing down hard with each breath. It really is a strange sight. The patient was given, oxygen, morphine, lasix, and hydralazine and guess what? It worked! And worked quicker than I thought it would. The patient was stabilized and stayed on telemetry.

Oh hell. I can not draw or write poems. Here are some pulmonary questions like the test questions. The answers are highlighted in blue.

1. The patient is 1 day post op from AAA repair. She develops atrial fibrillation with subjective dyspnea. The heart rate is 121 with normotension. What pulmonary complication might this be from?

a. Pneumonia

b. ARDS

c. Shock lung

d. Pulmonary embolism.

2.The patient is recovering from a right lower lobe lobectomy by VATS procedure. There is significant subcutaneous emphysema in her upper chest and neck area. As her nurse should recognize that which of the following is the highest priority?

a. Maintaining the airway

b. Assuring patency of the chest tube

c. Administering oxygen at 2 liters nasal cannula

d. Suction the airway as needed.

*apparently the emphysema travels upward by chemical nature and can put pressure on the airway. I have only felt those rice crispies once.

3. How does a D Dimer lab test help to diagnose pulmonary embolism?

a. positive test indicates PE

b. A negative test rules out PE

c. A positive test rule out PE

d. A negative test indicates PE

*That is right people, I made it bold blue for a reason. Elevated D Dimer does not mean PE!  Stop freaking out over the elevated D Dimer please.

4. The  patient was admitted for an acute stroke. The patient is alert but has left-sided weakness and is having difficulty swallowing. This morning the patient is short of breath and has rales in all lung fields. The most likely cause of this distress is

a. PE

b. Aspiration

c. Heart failure

d. Neurogenic pulmonary edema

* Swallow evaluation please, happens all the time. Stop feeding the acute stroke orally till the patient can swallow properly. ughhh

5.  The patient comes to the emergency department with an exacerbation of COPD. The patient is hypoxic and hypercapneic. The patient does not want to be intubated and does not want mechanical ventilation. What criteria are necessary to initiate bi-level postive-pressure ventilation (BiPAP)?

a. Must be able to slow down the breathing and not fight the machine

b. Must be able to maintain his own airway

c. Must be less than 75 years old.

d. Must quit smoking first

* And not be puking into the BiPAP mask. Also less than 48 hours.

6. Nursing interventions to decrease the rate of hospital acquired pneumonia include

a. Placing gastric tubes through the nose

b. Brushing the patients teeth

c. Administering systemic antibiotics

d. Keeping the patient NPO

*yeah oral care

I will inhale the rest of the pulmonary section tomorrow. I got lazy today.

I am going to dream about pink frothy messes sans respiratory distress.

i love you respiratory therapy department

I am going to write about some people in the hospital that have always taken care of me on the job. Everyone knows about how nurses often treat new nurses and while I did not have any major terrible experiences with the experienced nurses it seemed early on that the respiratory therapists around along my journey have turned my new and lately not so new nurse experiences into an irreplaceable affection for the respiratory department.

This tenderness was clear to me from week two off of orientation and my first code blue.  I walked down the hall on the way to another patients room and I see while walking by the room the patient is ripping off the gown and appeared to be in distress. I go in the room and the patient goes into cardiac arrest, I got no pulse, so I call the code blue and the first person to arrive is the RT (cause he just always seems to be around) he just started bagging and I just started compressing till  the code cart arrived and everyone else just came in and started working.  The whole time while trying to resuscitate the patient I see my RT ventilating the now intubated patient squeezing that bag and trying to find my face that was lost while trying to blurt out the facts about the patient and answer the questions that the intensivist kept trying to get out of me while desperately trying to find the differential for this problem. All I could see was his face filled with empathy, knowing this is my first time and knowing that I was 2 weeks new. He was just so calm and steady at the head of the bed doing his job and assessing the scene. I was so nervous, everyone was doing their job, chest compressions, emergency meds, checking the rhythm, feeling for pulses and there I was all new…racing with verbage out loud to try and get all the information out and my words were directed towards the probing intensivist but my eyes and speaking were fixed on RT because it was the only way I could read off of my paper and explain the patients clinical facts without losing my thoughts amongst the chaos. I just really wanted to be inside that ambu-bag hiding, but of course that is not possible: I would not fit inside anyway!   And when it was done he did not just walk away like everyone else did,  leaving me with a trashed room post ACLS for 40 minutes with drug vials littering the floor, a code cart empty, and a dead body staring at me.  He was there till I told him to leave so I could clean up the patient, perform post-mortem care, and bring in the family.

That was just the beginning of my fondness for respiratory. It was over and over again, every week a rapid response, and every time RT was there: performing interventions with this calmness that screamed to me: it is ok new nurse lets just get it done: the bedside intubations and transferring to ICU over and over again to what started out as worry and fear for me the first year lead to the second year turning to frolic and probably inappropriate but relieving humor of you wanna play this game again nurse?  It got to the point that when I found my patients in distress or anticipated distress I would just call RT on his cell phone and tell him…guess who? (as if my voice is not the dead give away) I am about to call a rapid response on my patient can you come to the room now?

I will not soon forget the intubation with thick pink frothy fluid spewing out all over while I am gasping out loud literally and oh my Godding and what is this stuff with descriptions (and making a funny spectacle)  and then laughing while sucking it all out all with my unconcealed surprise and giddiness at my aggressive suctioning and fumbling for my space around RTs  hands as he tried to intubate my patient, all while thinking this is not the same nurse as last year. And when that episode was over and was succesful he starts pushing me slightly to laugh about my reactions and animation.

This affinity towards some of the RTs at my hospital is not just limited to effective super skills in an emergency situation.  They just generally make my day brighter, listen to my rants, make me smile and they cheer up my patients, assess our patients. I feel at times like they are following me, or I am following them especially during my first assessments and I find all my patient’s oxygen saturation around 100% because they are all getting blasted with 6 liters on the nebs and I can not get my oral temps at that time either. When all 48 beds are full and all 48 patients are being nebulized I like to take down the treatments on my patients when they are done to get them all happy.  I remember at first wondering…is this done yet and shaking up the device to see if there was medicine left in the cup or not and was so embarrassed when RT saw me doing this he just started telling me: 1o minutes, or 20 minutes depending on how much of that stuff that comes out of little plastic vials is being administered. I always get happy when RT slips those little extension connectors into my pockets for oxygen tubing for patients that need oxygen therapy, or home oxygen patients to walk to the bathroom, it just gives me a giggle because I can not stand when nurses cut the oxygen tubing to make the connection and it always seems to look ugly and come apart during treatments (ugggh drives me crazy). So I always have some and even nurses ask me for them knowing I have some slipped into my pocket.  

The rest of this post describes some breathtaking (no pun intended)  RT bloggers that I read every post (only just 3 of them) and a few of my previous posts related to my experiences with the respiratory therapy department at my hospital (I left some out due to laziness of searching for them) and I left out the rant about ABGs not being drawn on time for my patients because they were not ordered STAT. (but heh I understand and get it).

So with all this attention towards the respiratory department especially after the first code blue I found  Keep Breathing and have been reading him ever since. His kind words after my sadness and guilt over that first code blue  really meant lots to me.

This RT made me laugh so hard when I was feeling like green poop from the job. I mean I came home feeling all crappy and stumbled upon his description of Ventolin types and nearly peed in my pants from laughing so hard, and I was no longer feeling crappy from work I was feeling the pleasing release of laughter endorphins. It is my perfect dose of humor, my style, and his blog is so educational I love it.

RTs are important, we all know that, this house MD made us all laugh when during a rapid response he wanted to know where the hxll the RT was…we were like dude…the RT is right here. (bagging the patient duh)

RTs usually get the ETT  in the first time…at least in my experiences so far as still new nurse *giggles* but sometimes they can not and that is when a stat page to the anesthesiogist comes in right on time.

This future RT writes about all kinds of experiences from different perspectives in health care and he likes trauma too. I cried reading his post about a pediatric code blue, something that I would never be able to handle (I am strictly adults) his writing is genuine and I feel for his experience and need to get it out there.  He is really going to be a super duper RT. (and hopefully nice to new nurses) !

And that is all I have to say about that except other cool factors to add: I always get the bag of ice ready for the ABGs that need to be drawn. I just like to. I will never call for PRN treatments that are not ordered or indicated. I will always laugh about what kind of trouble I will be up to each shift with you. I will never blast up the oxygen on the CO2 retainer. I will always put the patient back on BIPAP (instead of calling you to do it) when I am the one taking them off . I will always take down your finished treatments !

Anesthesia you rock

Listen to this nice calm narrator. Ahhhh.

 

Acute Respiratory Distress at change of shift:

A rapid response is called. We start ventilating with the ambu-bag which brings the saturation up and of course the patient needs immediate intubation.

So the RT attempts twice and does not get it in.

Another RT tries twice and does not get it in.

The MD tries twice and does not get it in.

STAT Anesthesia is paged: He strolls in all calm in his surgical scrubs and bandanna, we give him the stuff and he slips it right in, and strolls on out of the room, happily and calmly.

I am back

Oh! I went on vacation and have been totally out of the loop! I have to play catch up to read everyones goings on–in this sick I-am-not-alone world known as health care. I wondered how it would be to step into the work again after being on vacation as if I would of forgotten how to do my job.

No. Nothing of the sort! I started lines on my patients, managed the drippy drips. Helped people to poop (and pee). Provided emotional support for families. Listened to the hearts and lungs of all my patients and my own heart too! Fixed a flash pulmonary edema (again) as realized by: Shortness of breath, Hypertension, Rales 3/4 the way up the lungs, Respiratory rate >30, all in a patient with a cardiac history admitted with rapid Atrial fibrillation on amio drip and getting IV fluids of NSS @125ml/hour for the last 24 hours. I should of known to shut off those fluids as soon as I started working but I hesitated as the patient was dry and not eating and also renally impaired with metastatic cancer to top off the problems. So I let them run and then ended up: fixing the problem by: getting from the MD: (can anyone guess?) Lasix, Morphine, Hydralazine, and of course shutting off the fluids immediately.

The Life Vest and other report blunders

So I get report from one of my favorite night nurses (seriously, I luv her) It goes on and on about the patient, one part sticks out in my mind though, ” The patient came in wearing a holter monitor that she is not wearing now because she is being monitored on our monitors and she also has a chest tube to 20cm of H2O suction, status post lymph node removal in the operating room yesterday.”   I go to the room and find “LIFE VEST” batteries plugged into the wall, and I am thinking what is this?

The real story: Patient came to the hospital wearing a life vest due to an increased risk for sudden cardiac arrest,  and is status post  thoracotomy for partial lung removal with a chest tube to fix the ensuing  pneumothorax.

Two very different scenarios and care.

Arterial Blood Gas

Where I work it is the job of the respiratory therapist to obtain all blood gas samples on the floor. Most nurses are not certified to collect ABGs although if they want to get certified they can, by taking a test and doing a minimum of 5 ABGs in the presence of an RT to sign them off. Now I usually love love love the RTs at community X, but after this weekend, my patience has run dry.  I had 3 patients this weekend with respiratory problems and 2 of them were on and off the bipap and needing multiple ABG samples.   The patients needed it! The physicians ordered it! And the RTs gave me crap all weekend. One day because the MD ordered ABG today, the RT did not collect it until 10pm at night!

I am really sick of it. Now they all “do” their job in the end, but why do I have to be abused? Why do I have to call over and over “begging” them to do their job? Why do I have to be on the receiving end of negative attitude and nasty comments? 

Why does the patient have to be “coding” or near it for the RTs to take this stuff seriously?  And even then I still try to work as a team and when the results are back they do not even want to know about it! I understand that they short staffed and have lots of patients and they have to prioritize but HELLO! My patient in early resp distress with abdominal use for breathing and cyanotic nail beds that can not even talk is more important than the neb treatment to the chf patient that probably does not need it on the other end of the hallway is not more important than the ABG my patient needs now to determine how bad off it is.

I even offered to call the House MD to obtain my samples for them but of course the offer was declined. Maybe I will work on getting certified so my patients do not have to WAIT.

I guess I am just going to have to be the bitch nurse in order to get what I need done for my patients, and I never intended to be. That is what it comes  down to.

Image from http://www.trinityisp.com/~hartfamily/sampling.html

Todays Blue

So today the patient in the room next to one of my patients goes into respiratory…well arrest…she stopped breathing!  So the code was called and the response team came which of course included the RT–so the RT is bagging the patient and the House Doc arrives and says “Where is the RT?” Everyone was like duh…bagging the patient.

Anyway the outcome was actually ok this time.

Dear Respiratory Therapist

I was feeling down in the dumps about my job–how inadequate I feel at my job–the things I miss-the stuff I forget–how late I am at work every night trying to document all the things I did for my patients all day–How I wish I had more time with my patients making them feel better instead of worrying about how the “powers that be” at the hospital that is the administration are trying to move beds around–move patients around–etc…All this worrying and feeling alone about it–you know what I mean: try and express this feeling to other nurses and the aura or air about them is that they have time to do their job, spend time with patients and feel all good about their last 12 hours: this must be some sort of sick RN defense mechanism because I certainly on most days feel like poop.  Green poop from popping iron pills is how I feel on alot of days.I am not going to hide that truth from myself and I screw up, mess up, and forget things alot!

So in the midst of this self pitying, pity party over myself and my job performance and the lingering dwelling sad weight of all the patients that circled the drain ever in my now 6 months off of orientation memory: I read something that really made me laugh out loud.

I laughed all by myself out loud and thought, “if someone could see me they would think that I have lost my marbles!”

I just want to thank the RT responsible for this laughter because I actually felt some sort of weird chemicals being released into my brain that made me feel some sort of weird goodness or happiness.

Please for laughter check out these Top Secret Respiratory cures at the link provided. To get to the top secret treatments you must scroll down to the bottom of the page.

In your lungs.

Pneumo Vaccine: It always seemed to annoy me that in the acute  care setting I was worrying and spending lots of time making sure that all my patients were given a Pneumoccal vaccine. It seemed whether they liked it or not: if they fell into the category they got the shot. It is like a crazed mission to eradicate this type of pneumonia. Of course Pneumococcus has 80 different strains but the vaccine does cover 23 strains!

Well… as Karma, and Murphy’s law do work. I received a very sick young man with lobar pneumonia. The patient was very sick under the age of 25 and presented with chest pain, cough, pleuritic pain. Chest x ray revealed the pneumonia, and the patient was admitted to a general medical floor. The patient was assessed by the nurse to be tachypnic, tachycardic, and hypotensive, febrile. His BUN and creatine were elevated–the patient was becoming septic and going into mild renal failure. They transfered him to the ICU where he received close monitoring, fluids, antibiotics and aggressive treatments. One day after that the patient was transfered to my tele floor–stable, less tachy, still hypotensive and in alot of pain.  And the cough! IT was harsh. IT hurt me to listen to it.

The patient of course wanted to know when he was going home, back to his life, his job, not really knowing or understanding that it was not palm trees mountains or apples in his lungs. That he was seriously ill, and could not go anywhere anytime soon.

 The most common cause of bacterial pneumonia is Streptococcus pneumoniae or pneumococcus. Pneumococcus usually causes lobar pneumonia, attacking an entire lobe or portion of a lobe of the lung. The signs are usually: shaking chill pain in the chest while breathing, a cough, and blood-streaked sputum. This usually happens after a viral respiratory infection→ than bacteria get in.

I guess I do not mind so much injected those huge needles anymore into muscles–if it really helps knock out some pneumonias.

Negative Pressure.

I have been reading….and there still are some uses for these external pressure ventilators.

 

This is the modern negative pressure respirator!

She looks so peaceful!

This is just one of those concepts that amazes me.

It was this before…… 

This.