HA!!!
I am so busy in the morning. Especially during weekdays when patients go for more testing etc…I am making morning rounds and this i s what I find at the entrance to one of the rooms…
Telemetry art..using electrodes folded into eyes and a nice face.
I am always is hot pursuit of the creative endeavours but at least get your work done first!! (Like all the daily weights that are not documented)
Chest pain 10 out of 10 for 2 weeks- drinking fifth cup of coffee–eating italian hoagie–who packed her bag to come to the hospital last night! No ECG changes–Troponin negative–Chemistry and CBC perfect.
Allergies: Everything except Dilaudid.
Sure! Admit to telemetry with Diagnosis chest pain rule out MI.
Perfect.
MD orders: CCU labs times 3, ECG in the am, 2dECHO, Dilaudid q4 hours.
Are you serious?
Ok. I am on my feet for more than half the 24 hour day for 3 days in a row.
I spend alot of time at home in front of a computer, reading and writing (mostly reading)
My legs are crossed and I am like so afraid that I will get a deep vein thrombosis leading to pulmonary embolism leading to long term rat poison, anticoagulants that I immediately realize these implications and spring out of my seat and start walking and pumping my calf mu ascles and give myself a fluid bolus of 240ml through the mouth of course. Ha.
Who you work with on any given shift sometimes can make your day better or crack your twelve hours to pieces when you when you find your assignment in crisis.
I walked in on day one to crisis #1 in respiratory distress admitted to the floor by night shift RN who got ABGs and the patient on bipap but um….5 hours later I walk into this (the bipap is not helping) and the patient is getting tired with a breaths per minute greater than 40 who needs immediate intubation. And I am stressed out but somehow managed to be calm and I even surprised myself with how clearly I “knew” how to do what I needed to do, restraints, suction, versed….very different scenario 2 years ago when I could barely find my voice in a crisis and just wished I could blend into the wall and let someone else figure it out and speak for me. I have to add that I had the awesome st respiratory therapist by my side, the calmest critical care nurse across from me, the loves to teach physician keeping it all in perspective, as well as all the other helpful staff.
I walked into day #2 with a blood pressure in the 60s Systolic, clearly septic, on no antibiotics, and platelets count of 19 also struggling to breath and I knew and I felt sad. Blood was everywhere.
I walked into day #3 with a patient made npo in the night, diabetic on insulin and pills with a blood sugar of 30 and no IV access due to infiltration and no palpable vein in site or touch. I learned that the glucagonIM works in about twenty minutes.
The insanity is that I felt the adrenaline and I kind of liked it although of course it is a paradox as I would never wish that to be the norm. I think I am gearing myself towards emergency nursing or maybe intensive care at some point, sooner or later.
So the fake seizure in room #2 was annoying, but I regress.
Picture this: I am in the nurses station, the ICU RN has taken care of my intubated patient on day 1 while waiting for a bed to be available on the unit. I am officially relieved of my major responsibility for the patient and nurse A says to me all super loud, “You always get the worst group with sickest patients!” I am still trying to piece together what just happened so fast and my 4 other patients have not seen me except for my quick morning assessments and not one patient has been medicated. Nurse B gangs in and starts chiming the same tune and I am thinking what fresh hell is this? Nurse C starts ringing in with her sympathy for me and I lose my temper! They sounded like a bunch of cackling hens pecking at me…their morning bird food. So I flipped out and demanded the cacklers get out on the floor and start medicating my stable patients so I can catch up.
It worked! They scurried out and passed all my morning medications. I was able to assess my patients and spend ions charting in detail the crisis and all the interventions provided.
So I worked an extra shift today and how do I get thanked? By getting pulled to the holding tank where every patient that is admitted goes to that does not have an actual bed yet.
It is in the holding tank that you are stuck between a rock and a hard stone because the ED wants those rooms so they can assess more patients and clear the waiting room, (naturally) and the floors are stuck in a quagmire bottleneck half the time discharging and moving patients around and of course the nurse on the floor who is busy and refusing to take report right away…and your day is just a ball of angst.
Not to mention the fact that you are seen as the “intruder” sucking up the space of fast track…as if you really wanted to manage about 15 patients total, 4 at a time, see the patients for like one hour, not chart at thing and send them to the floor where you get bitched at by the floor nurse because you have had the patient for an hour and know little to nothing except what the previous nurse told you as they whisked the patient into your holding tank in the hallways!
Wow…the shift goes by really really fast.
I just feel so terrible.
I feel so “unethical”.
I had a patient this week, a man with cancer everywhere recovering from palliative surgery who was admitted to telemetry for blood pressure control with IV medications.
There was a note on the chart that said, “Please medicate the patient with pain medications around the clock per families request” because the “patient will not ask for it”
OK the patient does not appear to be in any pain. The patient did not verbalize any pain. The patient denies having pain and is resting comfortably.
Then…the family arrives and storms to the nurses station and demands to know when the last time the patient was medicated for pain which was over twelve hours ago.
They flipped out on me and now I feel disgusted with myself because it just does not seem right and only added to the patients confusion. Next time I am going to stand firm against these types, but the patient did verbalize pain after the daughter coaxed him by asking over and over again till the patient finally broke down and aggreed with them. err.
I tried to educate the family that pain medication is given as needed, not because you want to feel that you can control me and therefore control the decline of your loved one.
I guess me medicating the patient with pain medication was really medicating their emotional pain.
The one family member in particular was just so nasty to me!! And yet every time the patient needed hygiene care, such as changing the linens, changing his pads, they ran out of the room super fast.
Patient is 95 years old. Demented. Came from the nursing home with complaints of chest pain 10 out of 10. Family is complaining about the care at the nurisng home. The new heart doctor assesses the patient. The 95 year old female is happily eating her lunch with a big smile on her face.
New Heart MD: “What brings you here?”
95 year old patient: “I have chest pain.”
New Heart MD: “On a scale of 1-10 with 10 being the worst how bad is the pain?”
95 year old patient:” 10″
New Heart MD: “Nurse will you start this patient on heparin gtt and nitro gtt stat please.”
Nurse: (confused and perplexed) “Really? Ummm, I will wait for you to write the orders and then fax them to pharmacy.”
okey dokey! {I am not running though.} I mean is this MD serious? 10 out of 10 eating her lunch, smiling from ear to ear?
One hour later….Heparin and Nitro infusing quite nicely.
Nurse: “Are you having any pain?”
95 year old patient: “Yes”
Nurse: ” Where is the pain?”
95 year old patient: ” In my chest”
Nurse: “How bad is it on a scale of 1 to 10 with 10 being the worst pain in your life?”
95 year old patient: “10”
Nurse: “OK you can go back to your nap now.”
Seriously.
Later that shift I notified the Nursing Supervisor about the incident with the fake V Tach. I showed her the strip of alleged V Tach and the nursing supervisor was irritated because the med/surg RN kept calling her when I would not run up and get the patient off the floor the minute they called. (for good reasons).
The supervisor put the referal in to the education dept becaue even though this particular med surg floor only has 2 beds that can be monitored via telemetry the RNs working there should be able to determine V Tach versus Artifact.
Or at a minimum be able to further investigate the situation before playing musical beds musical floors all over the hospital.
Certainly I was annoyed to say the least, exacerbated by the med surg nurse “rushing” me for “nothing”
I am done ranting for now.
Just when you think you could not get any busier…..You get the page….it is a transfer from med surg. Now you know that the transfer is going to suck up all your time because the policy is…
Now of course number 3 never happens.
What happened is as follows. I go get my own stretcher, I grab my own Life Pak, I beg an escort to come with me. I get to the medical floor. The med surg RN is sitting at a computer charting. I get to the room, the patient has no idea he is being moved, wants to know why he needs that big scary Life Pak, and nothing is packed up.
The med surg nurse jumps up from the computer, starts packing up the patient and I am trying not to snarl at her for giving me the shaft.
This is the same nurse who called to supervisor because I did not call her back fast enough and the patient is not even ready. Yup she gave me the shaft.
Here is the best part of this whole story….
The patient was on a telemetry monitor for stroke protocol due to the patient having a possible TIA. Stoke was already ruled out.
The patient moved…..and the med surg RN decided that the artifact on the telemetry strip was V tach….
So without inquiring expert opinions from another nurse with more experience in interpreting rhythm strips or a physician, the med surg nurse calls the attending who by the way was a nephrologist, and she tells him that that patient had 7 beats of V tach. The attending then orders the patient to transfer to telemetry and a cardiologist consult.
I mean give me a break!
I did all this work, moved the patient why the med surg sat upstairs on med surg on her hind end charting at the computer.
I get the patient on telemetry, got 12 leads, serum chemsitry levels including mg++…and then guess what….???
I look at the alleged 7 beats V tach and find that it was ARTIFACT! Not even close to V Tach, narrow complexes very close together and only in 1 lead!
This is Artifact above us
So the above is Ventricular Tachyacardia. Image from AcuteResponse.
Not only did the patient not have any “run of V tach” the patient did not have any ectopy at all. So I am asking the med surg nurse…”Did he have PVCs? Did the patient have any labs this morning? Was the patient symptomatic after this (supposed run of v tach? Did you get a 12 lead EKG? Did you have the house MD see the strip?” No. No. No. No. No.
So I find this unbelievable that this is even permitted!
Then I get the call hours later from ultrasound…the patient was due to have carotid ultrasound and a transcranial doppler as part of the neurological workup and guess what? NO TESTS were done because the med surg nurse informed ultrasound dept, “The patient is to unstable and might “code” at any minute” and therefore could not go to and fro testing.
The worst part was when the med surg nurse said, “You sound irritated (well…duh, I am busy and you called the nursing supervisor because I did not run right up and take the patient off your floor.) I do not know why your so irritated, this is a really nice patient, it is not like you have tons of work to do for him, he is not complete care, not confused.”
WHAT??? “Working” for my patients is what I LOVE to do. Adding a patient to our census that does not need to be here is just one more patient in the ED that with severe CHF or a new onset of rapid atrial fibrillation or NSTEMI that will have to sit in the ED holding area waiting for a bed on telemetry, so that I can do nothing for the ruled out stroke, neurologically intact, “nice” patient who will have his testing done tomorow due to the unstable status of fake V tach as determined by med surg RN, who also might code at any minute. errrr.
Yeah Medical/Surgical Floor transfers to telemetry….love them every time. Usually the patient is totally benign on assessement or a totally septic patient tanking and needing to really go to ICU.
See Jane Nurse 
