I  remember this eccentric endocrine MD who when consulted on patients in the hospital for either high or low blood sugars. He would come in, look at the chart, see the patient on Amaryl, see the trend of blood sugars dropping below 50 and flip out in the nurses station about Amaryl and Kidney function and how patients with increased creatinine should not even be on Amaryl– in fact he was so adamant that NO patient in the hospital should be on Amaryl. There are just to many variables affecting the blood glucose of sick patients, especially decreased kidney function as we load many of the patients with antibiotics and lasix and CT scan dye (not to mention the NPO status half of the time for testing)!

I thought at first he was just out-of-the-box, eccentric, passionate, teaching nurses in ways that seemed to me way over my head as I tried to understand his lectures, but really felt lost. The bottom line is that I remembered and learned : No AMARYL for impaired renal function and extreme caution if the attending family doctor is ordering amaryl in any of my patients.

So today here we go……. internal medicine doctor admits patient 5 days ago to tele. Cardio on consult for severe CHF, patient getting massive doses of lasix, BUN and Creat are rising and rising daily. Patient is taking the Amaryl. ooooooooops here we go….blood glucose 27–nurse gives an amp of  dextrose–glucose goes up an hour later to 57–it is not enough! nurse calls internal medicine doctor and asks for IV fluids D10—MD says “No, I never have this problem at the nursing home but every time my patients are hospitalized you nurses are always calling me about this–feed the patient!” Nurse says that the patient is 90 years old and does not want to eat. Finally the MD “gives” in to D5%1/2 NSS at 100ml hour. Nurse is upset because the patient is in the hospital for CHF! Nurse is getting upset. Q 1 hour blood sugars are taken and the patients blood sugar is still below 60 and keeps dropping! Finally the nurse at her wits ends calls the House MD and a rapid response to treat the hypoglycemic cool, sweaty, confused patient and the patient gets the appropriate treatment. The patient  had to transfer to ICU for q1 hour blood sugar checks and all the while I am thinking, ” This could of been avoided if the AMARYL was never ordered!”

Patient Advocacy: If you are not getting the treatment you need for your patient you have to go elsewhere.

I tried to look for a quick article on Amaryl and renal impairment and could not find one yet, but it does not matter: I SEE this happening again and again! I even heard it could take 3 days to get the medication out of the system if the kidneys are impaired so if your patient has a poor appetite, in kidney failure, and in the hospital: Don’t give the Amaryl! I would rather give the insulin with meals and chase the coverage then to go through that again!

At the end of my last shift………The ED calls to give report. The diagnosis: peri-prothestic hip fracture, male in his 50s. The nurse tells me that the orthodude tells her to “admit the patient to where we normally admit”   So I stopped her immediately. I says to her “This is tele not ortho…Don’t ya think the orthodude wants the patient admitted to the ortho floor?”  She actually admitted that her and the ED doc figured the patient should be admitted to tele for the high blood pressure with no history of HTN. What? The patient had 10/10 pain and a blood pressure that normalized after the administration of morphine!

This is one example of a totally inappropriate admission to telemetry. We are not even “set up” for ortho! So of course when the patient required traction–it took hours to get the equipment and then find and ortho nurse to come down and set it up for us.

Pathetic!

I’m sticking to:  TELEMETRY/PCU

Ortho patients should go to the ortho floor.

It just seems unfair to us! Imagine the ED nurse calling the ortho floor to give report on a patient in a rapid A fib on a cardizem gtt and heparin gtt. ! All hell would break loose! The cool nurses on ortho would not manage that so why should I have to deal with bucks traction on a patient that is now normotensive with no cardiac history?

The bottom line is this: The ED nurse entered the admit to telemetry orders into the system before she got the order from the attending orthopedic surgeon: and the high blood pressure was the excuse to cover it. The bed was paged before she even got the order!! UNBELIEVABLE ! 

Admit to tele. Admit to tele. Admit to tele.

Don’t ever send me to ortho……….pleaaaaaaaaaase. It scares me!!!

OK I have been a lazy nurse blogger.

I should study for the PCCN exam! Yaay! (not) It is so hard to get back to test prep.

Anyhow…..Here goes a test question– an easier one on the pretest

1.  A patient with admitted with heart failure is on a diuretic and fluid restriction. Assessment indicates atrial tachycardia with a rate of 130, presence of crackles in all lung fields,  an S3 heart sound at the left apex and a blood pressure of 90/40 (previously 130/60). The patient reports feeling short of breath. The nurse should anticipate the administration of………….

(mulitple choice question–pick 1)

A.  a fluid bolus to enhance preload

B. dopamine to support the blood pressure

C. dobutamine to augment cardiac output

D. adenosine to reverse the tachycardia

wOOt! who knows the answer?!? (answer below)

C. dobutamine!!!!

I am studying to take the PCCN exam in approximately 2 months! I did the pretest to see how I will stand up without studying first. I did great on the cardio but terrible on everything else!! Imagine that? The ABG analysis killed me! The endless questions about urine osmolarity perplexed me!! Mostly because the questions were not is this ,or is this not normal, but rather, “What is the expected intervention?”

Just when you think you are super duper cool nurse, you find out the impossibility of knowing it all.

I guess I will just have to take only patients who are: Acute MI, NSTEMI, CHF, A Fib,  Acute Pulmonary Edema, Pulmonary Embolism and Sepsis!!!!!             

Is that all I have learned so far?

Studying will commence immediately.

I feel so special.

Oh and if you do not know what the PCCN exam is click here on PCCN.

Oh and Nurse K has a sadly amusing post about admissions and bed shortage and telemetry beds: click here. And read about the shell game. It is true to the word. A few weeks ago I started the shift with 6 patients: Sent 2 to the medical floor, 2 to rehab, and 1 went home. Guess how many admissions? Ironically the 2 that went to rehab and the1 that went home were long gone before the medical floor would take report on the other 2 ! I am not sure how it is possible that every time I call to give report they are, in an isolation room, or having lunch!?! I can only imagine the wrath if I did not take report from the emergency dept on a patient immediately ! We just do not do that on my floor, the sooner I get the patient the better for me and the patient and the hospital.

So I work in PCU. Part of the care delivered in PCU is blood pressures/complete vital signs and assessements every four hours.

12 noon assessments come quickly, almost as soon as you are done rounding your first assessment it is time to do it all over again. This frequent assessment is pertinent to progressive care, it seems that the acuity of these patients can often change that quickly.

This one particular shift I get to one of my patients on a few blood pressure medications but not anything out of the ordinary. I had just medicated him maybe 2 hours prior. He is in for chest pain: ECG normal sinus, no ectopy on the monitor, cardiac enzymes negative times 3, 2dECHO normal. No chest pain since admission to the floor 3 days prior. The patient has a history of hypertension and dementia.

I find the patient resting comfortably in the bed, no chest pain, pleasantly confused as usual, but severely hypotensive especially compared to his baseline of Systolic blood pressures in the 130s. His blood pressure now is 78/43. I check the other arm, 74/43, I get a manual blood pressure of Systolic 80. The patient is sinus rhythm- no tachycardia. The patient has no signs of infection, no white count, normal electrolytes. I was perplexed: It could be cardiogenic with the admission of chest pain, it could be a far fetched sepsis situation. I do everything. I get a more experienced nurse with me. While she is starting normal saline solution, getting all the labs including: coags, troponin, blood cultures, lactate, CBC, chemistry, inserting foley catheter, urine samples , inserting an 18 gauge IV catheter into the antecubital, all while I am on the phone with the attending basically obtaining all the orders for what we are already doing. We end up getting a fluid bolus of Normal Saline 500ml- then 125 ml per hour, and call the cardiologist to come see the patient.

We also find the patient soaked in his own urine (prior to inserting the foley) and diaphoretic. Blood sugar is normal.

Approximately 30 minutes go by during all these interventions that started with the fluid bolus. The patient is still hypotensive with a systolic blood pressure in the high 70s.

Stat ECG= normal.

The experienced nurse tells me to write all the verbal orders.

The experienced nurse tells the nurses aide: ” Get all the clean linens, we will clean him up and then call a rapid response.”

I was all laughing inside because she has got her priorities straight, right?

Everything was fine. The patient was basically asymptomatic, all the labs were normal and the patients blood pressure improved into the 90s and then low 100s. He remained on NSS at 125 ml per hour, and everyone was happy.

Except the patient of course pissedoff about the foley catheter. I felt his pain but refused to take it out so that we could monitor the output with all these fluids.

And of course all the medications were discontinued.

This was a good outcome! A rapid response was not called, the patient was stable, and became normotensive! How many times do we find a patient with a low blood pressure that ends up with severe sepsis, or some other ICU requiring transfer?

Yaay! One up for the immediate good outcomes. I am still unclear of the etiology? Maybe the medications, or maybe the patient was just volume depleted.

I was so amused by the experienced nurses calm demeanor. “Let’s clean him up then call a rapid response.”

Of course the patient presented stable clinically in no apparent distress.

The latest edition of change of shift is up over at florence dot com ! And I am included in this virtual care plan! Yaay! There are some great posts over there so happy reading!

Because I work in the greatest community hospital of all time! And your attending internal medicine doctor has the weekend off, the covering MD does not feel like discharging you because that would be to much work to coordinate that with your nephrologist and cardiologist: you can sit here till Monday right?

And why is nephrologist not included in my spell checker? errrr. Did I spell it wrong?

Part of what makes the work in health care so much more stressful is the fact that some people are: sue happy, reject the fact that death is a part of life, and ignore the fact that doctors are humans too.

I just got finished reading part 1 of  WhiteCoats trial story and I am actually depressed.  I see it all the time at work: to the point that you can almost smell a potential lawsuit in the future with some family members as if they are just waiting for something bad to happen to their loved one. I have had family members sit in the room for 12 hours with a notebook, and write down:my name,  the time I came in the room, vital signs, medications given, almost everything I say, how I turned the patient, and so on and so on. It really is a hindrance to patient care because it does not make me go into the room and spend more time with the patient/family, in fact I just want to run away from those rooms and enter only out of necessity…and it compels me to sit down at the computer and chart all day about every minute detail just in case something happens and find myself, the doctor and the hospital in court.

And when you multiply this times all your patients, every shift,  whether or not the family smells like a lawsuit: you spend more time charting and less time providing emotional support and all the extra comfort that could be included in your care plan.  Because in front of the experts no one is going to care that you were holding your patients hand and giving a back rub.

And if you ever find yourself in that situation: the only thing that you will have is your charting, and unless something exceptional about a patient sticks in your mind, you probably will not even remember anything without looking at the chart. Of course we are all accountable but not infallible. Medicine is not a perfect science, it is not the end all, and every body is different. There are standards that will all strive to meet and even go above that, but we are humans.

The whole process is so dynamic, but the fear of being sued or labeled: negligent, or incompetent has got us nurses in chart overdrive. It is a bit overwhelming and this medical sue happy culture sucks: we even have our own acronym for this charting. It is called CYA–cover your ass, charting. I would much spend that time teaching my patients more, and providing the much needed emotional support as well and the medical interventions.

Dear Patient,

You have been in PCU for 2 weeks. You have had a 2dECHO, an ECG every day, continuous rhythm strip monitoring, blood pressure  checks every 4 hours times 24 hours for the past 2 weeks. You are on 3 liters of oxygen at home and in the hospital even though I checked you on room air your saturation was 96%. You have had a CT of the head, chest, abdomen and pelvis: all negative. You have had ultrasounds of all four extremities all negative for blood clots. You move your bowels everyday. Your urine output is adequate. Your lungs are clear. Your heart sounds S1 and S2 with the absence of S3, no murmers, rubs, or clicks. There is no neck vein distention and no edema anywhere (fat tissue is not edema).  You have positive pedal pulses palpable even after your heart catheterization which revealed nice clean coronaries.  You have upper GI series with small bowel follow through: normal. Of course you had an EGD and a colonoscopy: normal.

I have six patients of which you are one, although that is not really your problem. It is my problem, considering, one patient in end-stage  heart failure, one is in respiratory distress on and off the biPAP, one is confused and keeps ripping out IVs and bleeding all over the place and one is probably septic.

So I am sorry that I refuse to give you sublingual nitro anymore that keeps me in the room for lengthy periods of time reassessing your pain, your blood pressure and another stat ECG. Especially since you then turn around and eat a huge lunch that consists of a saltless hospital food burger and fries. And I realized after 3 consecutive shifts with you that it does not matter if I give you nitro, maalox, tylenol, or any other PRN medication that you have on board: they all work the same for you. It is the placebo effect of getting something that takes away your pain so I refuse to keep slipping that small little sublingual pill called nitro under your tongue!

The Maalox  and Xanex work just as good lonely patient: I am sorry I can not just hang out with you all day, because you never seem to have chest pain when I am in your room listening to you complain about how you just do not know what is wrong with you.

And even though you did not mind the huge work up that you just went through last admission (one month ago) that was all repeated this admission:  I am sorry that you have an internal medicine doctor and a zillion specialty consults that can not figure out your real problem. I get this feeling you do not want to go home for some reason: and I feel sad for you.  If you could just tell me what is going on maybe with the help of the social worker we can find out why you want to stay here. All this invasive expensive testing is a hazard to your health.

Love,

Your Nurse

Disclaimer: I am a firm believer in the fact that lengthy stays in the hospital with no identify-able acute illness is hazardous to ones health.  I am not burned out from patient care. I love my job. I do find irritation from time to time when I am super busy with acutely ill patients that need/demand my presence and prescribed interventions and feel overwhelmed by patients that need/demand emotional support but are otherwise healthy and figured out the best way to get the nurse in the room is to put on the call bell and express chest pain 10 out of 10: even as you enter the room and find: the patient in no distress, not short of breath, skin warm and dry: cardiac markers negative time 30 sets, no ecg changes and a totally benign assessment. So you do the whole chest pain work up routine again and it sucks up all your time and inside you find yourself angsty worrying about your other sick patients. And this repeats every 2 hours. I would love to be able to provide emotional support but unfortunately: airway breathing and circulation on my other sick patients left me with little time for this particular situation.

I am trying to give report to the night nurse, in the nurses station the scene is 16 nurses talking at once, 2 unit secretaries, a monitor tech, and about 5 nurses aides all standing around in an area  the size of a large living room. There must be at least 7 call bells alarming, some patient bed alarms chirping, and the noise factor is going to make my head explode.

I turn around and right in the middle of the hallway is one of my confused patients  holding up his arm with blood all over the floor, all over the hospital gown from the IV that he just ripped out,  and the patient standing there perplexed says: “When is check out time?”

aHHHHHHHHHHHHHHH. Why is that when it is time for me to go home, everything gets all crazy.

 PCU (progressive care unit) turns into PCU (psychotic care unit).  

Like seriously: Dear patient, I am checking out right now, you could of ripped out that IV an hour ago.

When I am taking report and something awful is happening, be it  a patient rapidly decompensating or general patient nuttiness: I just take over. That is what I do. Take over. That is what we should all do. Nursing is a 24 hour business and after 12.5 hours of intervening it is time to go home. Why do I have to be guilt-ed into staying late?  When I am on the receiving end of madness: I take it, and do my job. If I wanted clean stability I would go work in a doctors office. duh.

Time for me to check out.