In the holding tank

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! ❤

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.

Rage against the ME

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.

More on Sepsis

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.

Alive after the code

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. ❤