cat FIGHT?

I have been feeling this vibe throughout my patient care when it comes to certain internal medicine MDs and a certain cardiology group where I work, aka: the best place to work in the whole world. I thought at first that it was just me, that I was just imagining this rift due to an over active imagination and high tendencies towards drama. After last weeks shift work I have come to the conclusion: I am not imagining this, I am feeling it, seeing it, stuck in the middle of it, and my patients although safe, could have better outcomes if it were not for this rift going on. Can you imagine? Health care providers alert: this really is happening. I am not sure why or when it started but here is one example, that I am not even sure I should be blogging about. I mean it feels taboo to even write about. It feels like protected  going ons of inside hospital information. I have to get this off my mind though AND want to know if anyone else has experienced this AND how to best advocate for my patients during this what appears to be a cat fight.
(thinks about how to twist the facts and still provide an accurate description of what I am trying to describe)

This is not just one internal MD, it is a few of them and the cardiology group is a pretty big one and they stick together like a well trained military unit.

Example: Who is managing this patient?

Patient comes in for a urinary tract infection (besides the point really until the end of this example). IMD (internal medicine admitting MD)  admits this patient. The patient comes in with lethargy, and change of mental status from home. The patient is found on admission to be in a rapid Atrial fibrillation is started on Cardizem IV in the ED and admitted to telemetry. The urine sent from the ED reveals a UTI. So the patient also gets treated with antibiotics. IMD consults the cardiology group. Cardio does their job: Patient on Cardizem IV bridging to oral Cardizem, Heparin bridging to Coumadin all while checking diagnostics to determine perhaps why this patient has a new onset of atrial fibrillation, stroke risk, anti-coagulation risks versus benefits, etc… The IMD IMD “>presribes the antibiotics at a low dose for only 4 doses and then discontinued. The patient is well controlled on IV cardizem without any side effects or complaints. So the Cardio MD prescribes oral cardizem and discontinues the drip. (usual right? yes.) Unfortunately the patient who does not trust the medical profession does not want to take the cardizem pill. Why? Do not know, she just does not like it, does not want it. So the IMD comes in every day (after the cardiologist is long gone)  and takes the patient off oral cardizem because he knows the patient does not want it, and prescribes digoxin orally for the patient. The patient only trusts IMD and if IMD were to explain to the patient: “You did well on IV Cardizem the oral will be good for you and you are being treated by knowledgable experts of cardiology and I trust your care with their prescribed interventions for you.” Here is the problem. IMD does not load the patient with IV digoxin. The  pre=”The “>cardizem drip has been off for a while, then BAMM right back to Atrial fibrillation with a rapid ventricular response. Here we go…this is where it gets fun. RN calls Cardio right? Tells the Cardio MD:  uhhhggggg. I have to tell you that patient so and so of IMD that you are the cardio consulting specialist is back in rapid a fib….and….IMD discontinued the oral cardizem after you left today, started the patient on oral digoxin, the patient has gotten one dose. The patient is symptomatic, uncontrolled and now hypotensive and from shift report the nurses tell me that this is the third time this week for this same patient. RN says: what do you want me to give this patient to control this rate? Cardio MD says: I want this patient on Cardizem. UGHHHHHHHHHHHH! Cardio MD says: “call IMD and ask why he keeps discontinuing the cardizem or ask him why he consulted cardiology in the first place.”

 He then says, “Ask him if a cardiology consult just looks good on paper even though you rescind the prescribed intervention?”

NO. I am not getting in the middle of this. I am tired of it! (this is one example of a few just from lately from these doctors)

See in my humble nurse opinion:

3 times cardizem IV went up on the patient. The cardiology knew that IMD kept discontinuing the oral cardizem at the request of the patient who is not mentally intact by the way. IMD kept ordering digoxin orally. They both see this and know what is going on. They are both taking a stand against each other but no one is managing the patient. The IMD could of let the cardiologist manage this, the IMD could have called the cardiologist and said, “the patient does not like the cardizem, is there an alternative solution? (of course there is). The cardiologist could have seen that the IMD kept prescribing digoxin and could have written orders to load the patient with IV digoxin and maybe some atenolol on the side to go with it, but hey: I am just a sort of new nurse that notices the trends in what medications control heart rates. And guess what else the IMD did? Discontinued the IV antibiotics after four doses and 2 days later the patient is febrile probably exacerbating this fast heart rate even more. (RN cries for help) Why?

Can anyone believe this?

It is not all internal medicine MDs, just a few and they are only doing this to this one cardiology group (not to any of the other cardiology groups.) So I do not know what their problems are (well yeah I know) but it does not matter! My patients need better management and I am begging for it, stuck in the middle crying. I understand cardiology making their statement: “If you want us to manage on consult: LET us do our job.” I sort of understand the Internal Meds: but not when it gets this far out of hand and not when your patient comes in with a UTI and only 4 low doses of antibiotics are given, and the patient is febrile, with mental decline and hypotensive, and I ASK for orders for antibiotics and IV fluids and you tell me no AND the patient is in uncontrolled atrial fibrillation and you tell me let us just monitor the patient. Uh no no. Sorry. Not me today. I will get the Cardizem bolus and drip up per cardiology AND some IV fluids for hypotension  per cardiology AND I will not tell you that I am at this moment: Getting blood cultures times two, a urine sample (that we already know is positive!) a CBC, Chemistry, Lactate level, and coags!

And guess what! 2 hours later I call you with these results and interventions: Your patient has a lactate level >4, is hypotensive getting normal saline per the cardiologist, the heart rate rhythm is still uncontrolled (although a bit better thanx to cardio), the white blood cell count has doubled since yesterday! Your patient is febrile refusing tylenol because he thinks we are trying to slip him a cardizem pill (did someone tell this patient not to take oral cardizem or what?) and anyway the patient is probably to lethargic to take pills now,  AND the house physician has transferred the patient to the intensive care unit  AND would you like to consult a critical care MD for ICU management or are you coming in to see the patient?

Anyone out there understand  or relate ? because I am just shocked by this childish mis-managed behaviour. We are health care providers, not big egos waiting to be stroked! (or what ever the heck the problem is)

*Disclaimer: I feel better getting this off my mind but if any patients or future patients are reading this please note that this is not normal, not the usual, and not all MDs no matter what specialty.

dictation dream

wow! listen to that rhythmic dictating voice!

Oh dear Radiologist. My day was going smooth. The usual, nothing out of the ordinary. Found myself performing nursing assessments, medication administration, monitoring signs, changing a wet pad here or there, educating patients, providing emotional support, titrating heparin, hanging cardizem drips, checking labs, calling doctors, the same old same old. Wendy, the medical surgical nurse of 5 years who is new to PCU nursing and acts like fresh grad sucks me dry cause she can not keep up and drowns every shift within her insecurity and lingers on tasks and symptoms of a lesser priority and I pity her cause I remember my first six months of my nursing career. I start her IVs, listen to her worries. Yesterday while she was drowning consumed by family members, she asks me to call the dictation line and get the results of a CT scan on one of her patients.

It goes like this: patient gets testing, radiologist dictates into the phone the results, and someone in some dark office transcribes the verbage and it appears in the computer hours later. When you can not wait hours for this to happen, you can call the dictation line and listen to the report recorded straight from the radiologists mouth. Sometimes if it is urgent: like MRI for stroke, you might call the radiologist yourself or if the radiologist calls you, well then you know the results are not good.

It is just the process.

Yesterday lost in my own mind, I call the dictation line for Wendy. I have my finger on the number 3 button on the phone for short rewind because usually they talk, dictate so fast you have to keep rewinding to make sure you hear it right and write it down because you will most likely be calling the MD with the results.

I hear his voice, calm and steady, speaking in paced controlled intervals and I see him in my mind starting at the top and looking at the scan and hear him describe the anatomy from the chest to the pelvis, landmark to landmark. His descriptions force visualization in my mind.

it goes chest (findings findings findings) space (findings findings findings) period (findings findings findings) comma (findings findings findings) period. (findings findings findings) next paragraph(findings findings findings) comma (findings findings findings) period next paragraph

abdomen (findings findings findings) period (findings findings findings)  comma (findings findings findings) period next paragraph

pelvis (findings findings findings) comma (findings findings findings)  space (findings findings findings) period (findings findings findings) period (findings findings findings) comma (findings findings findings) period

impression  one (findings findings findings) comma(findings findings findings)  period  two (findings findings findings) period  three (findings findings findings) period dictation number blah blah blah blah

It was so competent, so complete, I was impressed amazed and happy. I hung up the phone and announced at the nurses station. I think there is a new radiologist in town and his voice is a dream that I almost stopped writing while listening verbatim. I did not get his name at the end of dictation but I know he  is hiding in that dark room reading images right now and I think I am about to go down there and tell him “I love your voice and your dictation skills are awesome.” Of course I have no time to bust into the dark room and actually do that and it would appear insane anyway, so I think about calling on the phone and the unit clerk says “I think you should call him and tell him, so many times calls are only made to complain, do something random!” I look at the four digit number on my clipboard: the direct line to the dark reading room. I pull out my hospital cell and get ready to dial…..the telemetry monitor starts screaming, some patient appears to be in SVT or a rapid atrial fibrillation ( can not really tell with a rate that fast)  up to the 200s. I look and find it is my patient alarming. Cell phone goes in the pocket. I walk briskly to the room. My patient is hardly responsive, hypertensive, febrile, and the bed is soaked with urine.  The family at the bedside has that worried look. The nurse aid escorts her to the hallway. I take out my cell phone and call for assistance. Everyone comes, the code cart is rolled in. Another nurse brings supplies that might be needed to save someone from unnecessarily opening the code cart. The patient is stabilized and rate controlled with a cardizem bolus leaving her in a better controlled atrial fib but the MD still wants her in the unit. I try to change her wet pad before she is rolled up to the unit (priorities!) but the critical care RN begs me to stop so I do. They wheel her up for me, cause it is shift change and the nurse relieving me is waiting for report. I sit down in my chair, it is over. I look at the four digit number to the reading room. Give report and go home. Never did make the call.

up to speed

Since everything has basically gone paperless at the greatest community hospital in the world aka where I work, I wonder when and who is going to bring some of the physicians up to speed. Dr. Wants To Be Spoon Fed by the nurse who is on my annoying doctor list (the list is not that big really) stands far far away from nurse Jane, yells across the nurses station, “What medications is the patient on?”. I say “it is in the computer” so of course he does not go to the computer to look, he fills out the discharge medications section: same meds as at home and leaves. Really? The patient was on coumadin and came in with a hemoglobin of 5 bleeding out the rectum and he writes same meds as at home? Now in total irritation and major frustration I have to call him on his cell phone and read the list of medications from the computer and take telephone orders for the discharge medications to be totally compliant with the discharge policy and to prevent the patient from actually following those instructions.

i hurt my back

somehow and I was not even at work. I can not move greater than 15 degrees to each side or bend forward more than 10 degrees. I broke down in pain and went to the *gasps* doctors. The NP thinks it is just a muscle spasm, and now I am taking: ultram, flexeril, lidoderm patch and REST. ughhhhhhhh. I never have had any problems before and I hope I am better in 3 days before my next shift: ouch

coffeeeee

Lasix 40mg PO bolus

20 meQ KcL PO

I seriously think that all the coffee inducing diuresis* requires some sort of electrolyte replacement.

I am going to start monitoring my I/O.

Eternally nerdy.

as if i have time to pee!

 

*peeing your brains out.

Dynamite

During the 1860s workers at Alfred Nobels dynamite factory who suffered from heart conditions noticed that (opposite to most of us) their chest pains eased once they once they came to work. It was eventually discovered that nitroglycerin dilates the blood vessels, which provided relief from clogged arteries.

From: the complete idiots guide to Fun Faqs.

Nitro is cool.

Burned out neurons

I feel sick.

I always rant and rave about how much I love telemetry nursing and usually I do, but right now after these last few shifts I am on the cusp of burning out.

I do not keep active in the health care debate, but I do know this:

Where I work: everyone is admitted for every small and minor complaint. Everyone gets huge diagnostic workups that take days to complete with at least 3 consultants. Internal medicine MDs are afraid to discharge, consults leave it up to the internal meds to discharge and yet the tell the patient they can “go home”.

I know this: when everyone is standardly admitted, noone seems triaged.

And when someone is sick and it all rests on the nurse caring for non-acute other patients: the nurse gets burned out.

People are dying all over the world of treatable diseases and over here at community I had a patient tell me today she was “shopping” for a  new hospital.

And yet: I get an admit from the ED with HTN, dizziness, nausea refusing blood pressure medication and could not “tolerate” the indicated CT of the head due to her being nausea when she lays flat.  Well, wow…what can I do for you?

Helloooooooooo. Is anyone out there feeling this? My neurons are burned to a crisp.

IV lamps

These are so cool

I want one in my living room!

Ok. I love my job. Call me  crazy but I think these mock intravenous pole lamps totally rock! Sure most house guest may not even realize the mock IV pole lamps but who cares! I think they would make interesting decor! They should have wheels though, that would make these lamps even cooler, but they are just ice as is. Found over here:http://www.coolhunting.com/archives/2008/03/lichtinfusion_l.php

As the tele pack turns

Telemetry packs often look like this. We hook those wires up to patients and can see at the nurses station a continuous reading of heart rhythms and some even have blood pressure monitors as an added bonus.

Speaking of ICU nurses before I describe my last shift I want to mention a great blog post that introduced me to Nurse Sean: the post that summarized exactly how I was feeling at exactly the same time can be found here and the blog is here. Nurse Sean has been in my sidebar for awhile now and honestly I stopped clicking on his name for awhile but it appears that he is writing and I am clicking and reading.

Sometimes as a telemetry nurse things get crazy. Some of the patients are on the cusp of being critically ill while some are apparently stable, with unstable angina seemingly on the stable range of the shooting field. Some are admitted honestly by MDs to telemetry because we take blood pressures every four hours and they feel that the patient is closer monitored even if they do not need continuous rhythm strip analysis.

Resources. Working in a community hospital resources are a precious commodity to me, a telemetry nurse. And that is why I felt guilty after my last shift. I got report from the night nurse that a patient was admitted from the emergency department after going to the doctors office for being “shocked” multiple times within the last few weeks by his internal defibrillator: after interrogation it appeared the patient was having sustained ventricular tachycardia hence the AICD was doing its job. Anyway he arrives to the floor with a systolic pressure in the sixties. The night nurse gives a 250ml normal saline fluid bolus bringing him up to systolic in the seventies. I check his labs and see that his creat doubled since yesterday, and of course I was concerned. I assess the patient who is completely awake and orientated, only complaint was “a little dizzy” and his pressure is again in the sixties. The patient appeared to be in no distress at all: no pain, no tachycardia, no shortness of breath, clear lungs, making urine,  just a “little dizzy”.

Every nurse on telemetry it seems is so afraid to run in fluids: mostly because more than half our patients are in heart failure or have a history of it. Every nurse who has seen their patient go from breathing just fine to acute pulmonary edema will know the fluids can be frightening: but giving a dizzy patient with a blood pressure in the sixties only 250ml of fluids and calling it a night is not quite right!

So here I am on day shift with the maximum nurse to patient ratio of 1:6 ( a crime). Tending to this patient giving multiple 250ml fluid bolus over an over again (slipping in a little extra here and there)  when I really just wanted to run in the whole liter in an hour. Wasting my time doing the whole sepsis workup when internally I felt that the patient was just dry: but I was not willing to risk that assessment alone. When at the end of the liter going in (in 250 increments) the patient was finally transferred to ICU for the inability to maintain a decent pressure in spite of a liter of fluids: with scheduled anti-arrhythmic  medications to prevent further ventricular tachycardia that would lead to another “shock.”

Needless to say the patient received another liter in ICU: and was transferred back to telemetry the next day with a normalized pressure, and guess what? BUN and creat back to normal! and no other problems.

I honestly felt guilty like I misused a valuable ICU bed for some gentle fluid resuscitation. But in the end the guilt goes away because to many times, the call is not made early leading to poor outcomes. And to many times in community the ICU bed is not available, and transfers into ICU are actually triaged for the sickest to go in first while the other less sick patients ( but still critically ill) stay or get transferred in to telemetry waiting. When that happens the shift becomes a circus riot and your stable patients hardly see you.

So the census is back to normal. The revolving door to telemetry is open for monitoring. I started my last shift with 6 patients. 2 went home, 1 went to a medical floor, 3 stayed with me, 1 admission from the emergency room and transferred to ICU before shift change and 1 was stepped-down from ICU into telemetry: and that was just my assignment, my group: the story repeats for every nurse that shift and we call it: as the tele pack turns.

5 Stable Patients

I had one of those busy (with paperwork and other mundane nursing tasks that we have to do~ the kind of tasks that make me think *i would rather be starting IVs for everyone on the floor* than to do this paperwork.)

Anyway at 7pm I give report to one of the night nurses that I find is so emotionally bogged down into this weird pseudo-relationship that: if you pick me all the time and we are together since we work the same days~i will calm down and not be a total nut job while your trying to give me report (that is night nurse). So it has been a while seen me and emotionally bogged down night nurse and I have been together. Together= we both work 3 shifts in a row every week on the same days and sign out to each other, making the whole report process much quicker: just updates. Me and nut job night nurse on day 1: I give report on 5 stable patients. It takes 43 long minutes of our time. Then we do rounds. Rounds=we walk into the room, I introduce you, you see the patient is in no distress, I leave, end of story. Well nutty decides to have a conversation with all 5 patients while I am impatiently huffing under my breath, trying to be polite but oh so irritated.

I say good bye and nutty frantically shuffling papers says out loud: oh my night is so busy I wonder how many of these people are going to code tonight.

What?

You have got to be kidding me or you need a new job.

5 stable patients.

1 nutty night nurse.