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   In my pursuit of finding out about this method I also found some other outdated medical procedures such as inserting mercury to break down a bowel obstruction!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.

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.

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.

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.

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

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.

After two something years out of nursing school and rolling on telemetry with all its PQRST intervals and drugs and QTc intervals and heart sounds and lung sounds and optimal electrolyte goals for cardiac patients.  AND  yes  to the Pharm D, I am aware that the MD just ordered Levaquin IV and the patient is on an Amiodarone gtt so I will call for a different antibiotic because I know after numerous phone calls from pharmacy that the Levaquin IV and Amiodarone IV may prolong the QTc interval and perhaps lead to torsades de pointes, and we all know to watch for those R on T– PVCs. Oh and I love the medical patients that get transferred to telemetry so that they can receive haldol IV because that too may prolong the QTc interval. *sighs*

I am  backtracing here like a regular sinus rhythm strip erasing backwards from right to left to the original pacer  of my heart.

What I want to write about is clinical can do skills. I just like clinical stuff. I would much rather start IVs and insert tubes and talk to my patients then to sit at a computer all day and chart check  (b o r i n g).   And I got a reputation for that in just 2 short years.

How did it start? Luckily for me I had a great clinical preceptor. This man nurse who orientated me for some 18 weeks on the floor is an older nurse from India (note: not to be confused with fave man nurse).   He actually went to medical school in India, and then came over to the USA, never completed residency and then just decided to go to nursing school. So he has been around for a while. He has great clinical skills. There is not an IV that he can not start on the poorest of veins. He is calm and relaxed all the time, even in a crisis and he just can do. I consider myself  lucky to have been precepted by him and I am lucky to obtain some of his calmness. He has the ability to differentiate a crisis  requiring help from others or we can fix it here and now situation. He was there when my first patient coded and actually inserted a femoral central line under the supervision of the intensivist during the code, so that the intensivist could manage the code! imagine that!

Starting IVs. After my orientation was over I deliberately scheduled myself on the days that he worked just so I could keep him a  resource. For every hard stick that I could not get the IV catheter inserted, he would be there for me. The thing about me is that I never left the room when he started my IVs, I wanted to stay to see what he was doing. He took a really long time on those who had poor vasculature. He sat down in the chair, looking , searching, palpating. Sometimes he would find a vein and show me and tell me to do it while he stayed with me and I would get it!

I was never the nurse to ask some other nurse to start an IV for me and then go do other things, even if I was busy and I never asked someone else to help me unless I failed on my own attempts. And now I am the nurse that other nurses ask to start IVs that they can not get! Practice.

And after two years, I get it mostly every time. How? Well, I had a great teacher and I start IVs alll day for everyone. When I am not busy or my work is done at 1800  hours I ask every nurse if they need any IV starts and then I make a list and get a bucket and go inserting. I love when I introduce myself and tell the patient what I am here for and they tell me, “I have been poked so much you will never get it.” and I just take a long long look and then get it in one stick, the patient gets so happy and relieved and it feels good hearing, “you are the best aren’t you?”   I blush and say no I am not the best, but inside I feel real good, as if at least I am good for some things.

I am not limited to IV catheter insertion. There is nothing more that I loathe more than gastroenterology and all of its aspects. The patient coming in with the huge distended belly either from a bowel obstruction that is probably septic or ascites from liver failure, it just worries me so much. I once had a patient code that I am sure was originally related to abdominal compartment syndrome. I mean the belly was so big and distended it appeared to suck up all the lung space! I mean how can one breath with a belly like that?  Here I am backtracing my ECG.

It is pretty darn bad when Belly Surgeon tells another nurse to find me to insert the NGT that she could not get in. I remember inserting my first NGT, I was in ICU still as a student and the cool nurse grabbed me and I was all shaky and nervous, and he just held my arm while he told me keep advancing, so I did, shocked at what started sucking out of that patients belly:  coffee grinds. The second NGT I inserted was equally nerve scraping. I asked my clinical coordinator to come with me, she held my hand, and I got it in.

Now my clinical coordinator wants to know why is the surgeon calling asking me to insert an NGT when just 2 years ago I was so afraid I could have peed my panties. I give all the credit to her by telling her remember you are the one who showed me how Miss. Reality check: I am just always around, if someone says out loud they have to do this, or have to do that, I just get up and say, I can go try it no matter how gross it is.  So doing it over and over again gives me this confidence that I would not have if I just waited around for it to always be my patient only that needs whatever intervention.

And just like it is always easier to clean someone elses house as opposed to your own, it is much easier to shove tubes into the orifices of  someone elses patient other than your own for some reason.

One thing about tubes that drives me into an irritated frenzy is this: Patient comes in with a bowel obstruction or something like that and night nurse puts in a spaghetti noodle for an NGT and then tells me in the morning there is no output from the tube on low intermittent suction. I mean why bother inserting the slippery soft 12 french? Of course there is no output, that little tube is clogged probably with fecal matter silly and I am not about to mess around with it all shift. I learned this by going  in with the 18 french and getting a whole liter out immediately; I am not surprised as I watch the belly slightly decompress.

And decompression queen I be, and I kinda dislike that reputation given to me by Belly Surgeon.  It is sort of gross and I wanna be pretty darn it! *sighs* I mean if a surgeon wants to make up pet names for me I would pleased with the cute smart nurse or something like that. I do not like GI. That is why I work on telemetry to reduce the number of GI related patient care. Unfortunately I get them anyway, for whatever reason, electrolyte imbalances: transfer to telemetry or whatever other reason attending MDs can create.

I once had a patient with Ogilivie Syndrome. The patient was very sick from other illness but this problem was very discomforting to say the least, and seemed like one Kcl rider after another, I never infused so much potassium in my life as on this patient. Needless to say I called Big Belly Surgeon who informed me that when the potassium levels return to normal it will get better for the patient and also insert a large-bore NG tube and try inserting a rectal tube, the kind used for fecal containment on c-diff patients. Well I inserted the tubes and the belly went down. wow and gross. it worked.

If you work with me, I got your tubes, lines, and stat blood work, your ECGs too. If your patient is crashing, I got your 18 gauge in quick and the defibrillator pads on just in case. I just like to move, I can not sit for long and I got that reputation, let me do it. Even if it means speed charting at the end of the shift. My only distraction would be that darn dictator, I could sit for that and press 3 for short rewind a few times.

While skating on IV poles down the floors all tired at work and wishing I was home napping, or that someone would come in and work the rest of my stable shift I get a phone call from my favorite man nurse.  I was so happy to see his name on my phone as I thought: Yesss he will come in and work for me !

He calls wondering why I was not at work the day before which was my usual scheduled shift and to tell me how terribly upset he was that I was not there working with him because

He worked twelve point five hours without me suffering because

He has hemorrhoids !

And apparently they are bothering him something awful and he had no one at work to talk to about this discomfort all day and he was feeling kind of lonely about it.

Talk about a whole other level of comfort. wow. Does he want me to give him a suppository or something?

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 !

It has been 2 years and 10 months since I graduated nursing school. I will not summarize that in one blog post do not worry. What I want to write about is sepsis and how I ended up on this sepsis committee at work.

I am anti-social Jane. (*gasps*) I was not interested in the performance and improvement committee, or the wound care task force (not my cup of tea), or anything that would bring me into the hospital on my days off (other than mandatory education requirements). Yeap, even during my first yearly evaluation, I got a raise but was informed by my director that I lack involvement. *sighs*

Involvement. I had this sepsis cloud following me for a while. It seemed that every week I would get report, assess the patient and end up with a septic shocker spiralling down the drain in front of my eyes. Working working  working never leaving the patient, and worrying about the stability of my other patients since I was unable to even get to them. I kept seeing it over and over: hypotension, febrile, tachycardia, infection and risk factors for sepsis.

I was such a new nurse and I knew the basics of what to do but it was always a long drawn out process. I mean: I knew to get the blood cultures and some fluids and antibiotics but the process was so unorganized and ineffective. My patients always ended up going to intensive care  eventually, after I tried the minimal interventions ordered by doctors and waited for progress that sometimes never came. The interventions were minimal because I was not pushing hard enough to present the clinical situation. And my heart always sank into my stomach after the patient was finally transferred to ICU: and I hear: code blue ICU: and call up later to find out: yeap, that was your patient.

My documentation would read something like this: Notified Attending MD that patient is hypotensive SBP 70s, sinus tachycardia,  admitted with pneumonia, yesterdays CXR showing infiltrates, febrile, lethargic, WBC doubled since yesterday. Attending (usually an internal med) would order 250ml saline bolus, Tylenol, blood cultures, antibiotics.

And new nurse would do all that not realizing that 250ml saline is not going to butter the bread at this point in her nursing career. And she would call back the MD, give another 250ml bolus and go round and round and round . It is just not working.

And then she found me, or I found her in desperation and she recruited me: to the sepsis committee to educate other nurses about this, how to treat it, and how to get your point across to the MD when they try to order the minimal interventions that are just not enough (usually because the nurse is not getting the whole clinical picture into that phone call).  And she is the critical care nurse educator for the hospital and she runs this committee trying to get everyone on the same page.

I mean I can not write about every single septic patient I ever had, that would be too much. Just know that there are nurses who have patients in early sepsis on the floors and if it is not turned around, the patient is eventually going to get worse. I can not say how many times I have received report from the night shift about a patient with a blood pressure in the 70s and febrile and they call the House MD and get Tylenol and a 250ml fluid bolus and then call it a night without even investigating the clinical situation.

My deal goes like this now:

Suspicion of sepsis when:

You assess your patient and find any of these new changes in status: hypothermia, hyperthermia, tachycardia (not on beta blockers) tachypnea, acute change in mental status, hypotension, hyperglycemia (without being diabetic), tachypnea, leukocytosis (or bands > 10%), or leukopenia.

AND

Your patient has an infection or risk factors: pneumonia, empyema, UTI, wounds, foley catheter, device infection, central line. risks: long term hospitalization, nursing home patients, immunosuppression, aspiration, etc…

If you find those clinical assessments and you know your patient has an infection or risks you can guess on sepsis AND get blood cultures times two, lactate level, cbc w/ diff, and coags (PT/PTT). Where I work it is protocol,  just do it.

AND you do not stop there.

Does your patient have evidence of ACUTE organ dysfunction? (not talking about chronic conditions).  Is the systolic blood pressure <90 or the MAP < 65 or a 40mmHg drop from the baseline?  Yessss.  I have been there with my patients.  What is on that chest x ray from yesterday?  Are there infiltrates?  Do you keep turning up the oxygen on the nasal cannula to maintain a SpO2 >90%?  What is the urine output?  Is it less than 0.5ml/kg/hr for more than 2 hours? *gasps* when the foley bag is empty!   What is the creatinine? Is the creatinine >2?   What are the platelets?   Are they less than 100,000?  You checked the lactate when you initially suspected sepsis right? If you are on a medical floor and the lactate is >2 or definitely >3 (but still maintaining blood pressure) the patient needs to be transferred to telemetry.  If you are on telemetry and the lactate is >4, or >3 with hypotension the patient needs to be transferred to ICU. All of the above criteria resemble suspicion of severe sepsis and organ dysfunction and guess what?

We have treatments for this do not worry, just get it done.

Here they are by standard protocol and clinical judgement,  it is the sepsis resuscitation bundle to be done withing the first six hours.

1. Mandatory diagnostics: lactate and repeat lactate in 6 hours, blood cultures prior to  a broad spectrum antibiotic within 1 hour.

2.Optional diagnostics (usually done): CXR, cardiac enzymes, cortisol level, urine culture and analysis, EKG, sputum if you got it.

If you and your patient are on telemetry and you are already waiting for an ICU bed to be available: you start initial fluid resuscitation and if there is no response to the initial resusc you apply vasopressors to maintain a mean arterial pressure >65.  AND you are finding out who is going to drop in the central line.

  If you are on a medical floor you call a rapid response and let them start resuscitation.

It goes like this: for hypotension SBP < 90, MAP < 65 or lactate >4 you deliver: minimum 20-30ml/kg of crystalloid–then, NSS 500ml bolus over 30 minutes repeating till getting an adequate urine output or if you have a central line and are in ICU you want a CVP 8-12mmHg. If this does not work you get on the vasopressors.

After getting all that going hopefully your patient will be in ICU receiving further treatments like steriods, drotrecogin alfa activated maybe, with tight glucose control among all the rest of whatever they do up there so well.

So now my phone call to the MD sounds more like this:

Attending MD (with this verbage)  your patient is hypotensive with a systolic pressure in the 70s, febrile on rectal temp, has new tachycardia, acute change in mental status revealed by lethargy and confusion and the patient was previously alert and orientated, the patient (your patient) admitted with infection, white blood cells are doubled since yesterday, I already drew lactate and it is greater than 4, blood cultures have been sent. I would like to start fluid resuscitation at 30ml/kg, administer a STAT broad spectrum antibiotic and transfer this patient to ICU where you can continue the sepsis protocol and monitor CVP? Does that sound ok to you?

 

It just kept happening to me over and over, this sepsis cloud following me. After awhile I just knew where to start and ended up helping every nurse that cries in the nurses station: I think my patient is septic. I would just go get the basin, start filling it with blood tubes, foley catheter, 18-20 gauge IV catheter, normal saline, and just start working.

That is how anti-social nurse Jane got on the itty bitty sepsis committee.