Archive | October, 2009

he has hemorrhoids

26 Oct

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 love you respiratory therapy department

25 Oct

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 !

itty bitty sepsis committee

20 Oct

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.

 

cat FIGHT?

15 Oct

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

12 Oct
wow! listen to that rhythmic dictating voice!

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

7 Oct

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.

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