Archive | January, 2010

Where will I go now?

27 Jan

That was me after experiencing a real GI bleed for the first time.


I will never forget the first patient I cared for with an acute GI bleed. It was insane and bloody smelly. The patient came to telemetry after having blood in the stool and feeling weak and chest pain. The hemoglobin on admission was around 10 [not so bad right?]. The patient gets to the tele floor and tells me he has to poop. He looks pastey white and I give him the bedpan. I stay in the room and the smell really surprised me: I had always heard that GI bleeds were smelly. I turn the patient over to take him off the bedpan and find the bed pan full of frank red blood [and I did not see any hemmroids]. No urine in that bed pan, the patient had a catheter. The bed pan was literally filled. I called the GI MD and revealed this information and naturally the MD requested the patient to be transfered to ICU: there were 2 units ready in the blood bank [thanks to the ER type and screen]. The patient did not need to be packed up because the patient just arrived, we are leaving to roll the big bed to ICU and the patient tells me: I have to poop again. We are half out the door and I roll him back a few feet, shut the door, put him on the bed pan: he fills it with blood again. I sent the tech to the blood bank with the request slip and ask her to meet us in ICU and we go. This has nothing to do with this post, but the artwork above reminded me of that first GI bleeder. While late entry charting I could not resist checking the hemoglobin that was drawn 8 hours after the first hemogram done in the ER: it was 6. <gasps> the patient was not actively bleeding in the ER.

The place I work has bad reputation, some of which might be  blamed on the nurses bitchy attitudes, but not entirely, there are some great nurses there. A lot of it has to do with the atmosphere, there is no space, it is loud and it is messy. Mostly I have felt that it has to do with the lack of leadership and control. There is no control. We are the red-headed step children of the hospital.

Is that why I stay there? Inherently drawn to chaos and instability by nature?

Why do I stay there? I like the fast turn over of spinning tele packs. I like skating on IV poles down the halls. There are some really cool nurses there to off-set those who are less-than-cool.  I like learning about all kinds of arrhythmias and the electrical conduction system of the heart and the effects of medications on that system. I am still missing retired Fave Cardio and still see him standing at our watch station saying to me: Holy long QT interval  bat girl, no wonder her family history includes early deaths. Just as I will never forget the first time I pushed Lasix 80mg on the heart failure patient filled with rales, I nearly peed my own pants looking at that big vial.  I get a huge thrill watching the heart rhythm in atrial fibrillation, pausing, pausing, then converting to sinus rhythm. [the artist in me feels that hearts struggle]  Nothing tops the code in ventricular fibrillation run by Zorro MD, blasting the patient with 360 joules over and over again: the patient lived with enough strength to try to pull out the ETT while en route to ICU after being stabilized on the floor. Everything I ever hated about Amiodarone was suddenly made up for on that day. [I still do not like Amio, but I now appreciate its usefulness much more]

I now have three years running on telemetry. I do get tired. The shift, the house census, the acuity, the assignment/floor all contributes to the stress level. There are many stable shifts, followed by: wow, some of these patients would probably be better off in ICU if there were beds available.  I mean it  is difficult to assess these patients every four hours or more often actually to do it right [and check the outcomes]  when there could potentially be six patients to care for. Even if only two are really sick requiring all of your attention, the other four still need you; and the ruled out MI is patiently waiting for the discharge instructions. [lifestyle changes +cake walk= i love my job] 

Tele nursing has been a  huge lesson in: prioritizing. Those questions from nursing school of: which patient will you go to first?  Is reality especially when the night nurse gives you  a patient having a systolic pressure <70 and you are thinking the MAP is greatly <65 [also thinking of hypo perfusion to the vital organs, did the patient even make urine?] and that nurse is acting clueless and you know where you will be for the first half of the shift.  It has been a chaotic dance where just when you think the routine is on task: you stop everything you are doing for the chest pain in room four. Or you go into the room where the DNR is dying with no family member in sight and hold her hand, watch the irregular resps, agonal, wonder about her life and why there is no family around, and throw another blanket on top instead of watching the monitor brady-ing down.

I plan on attempting to transfer to ICU nursing when a place becomes available. I like to assess patients, that is why I want to go there. I am obsessed with hemodynamics: If I had time I would be in my patients room measuring the JVP with a centimeter ruler.  Here is the thing though: I secretly harbor social angst inside. Fear of rejection: what if they will not have me?  I still feel like a new nurse after 3 years, although I do not deny the skills, knowledge and experienced gained quickly on telemetry. I almost rolled on the floor laughing last week when a so called experienced nurse, even with ICU experience was telling a new nurse [trying to interpret a rhythm strip] that she was looking at a burst of a fib: I almost died telling her: No what you see is a burst of  PSVT, paroxysmal atrial tachycardia to be more specific, just go ask Fave Cardio sitting over there.  Isn’t it easier to stay in an atmosphere of knows something, than to switch to knows much less. Starting over? Will they nurture me? Feed me to the wolves?  Should I take into consideration my personality? In the tele whirlwind of where I now stand, all the nurses think nothing of my high energy caffeine fueled mania. They are used to me, used to my chronic blush [idiopathic cranio-facial erythema], and my talking out loud, to myself or anyone who will listen. My co-workers love me! [most of them]. In my inner world of fragile security that means lots to me. transferring would mean no more skating on IV poles because then they would all know I am goofy!

The truth is I am a sucker for forever learning so the end result of this self debating of where do I want to go and who will have me?  I will be so afraid actually, but I will never know that I can do it [or can not do it] unless I make an attempt.

i hate asystole

14 Jan

epi epi epi

It is official, I have decided that I hate asystole or PEA codes.  Since my new nursling days that is almost 3 years ago today (I am still a nursling <3), I have been directly involved in a total of 4  code blues. I am not including respiratory distress with intubation etc because luckily in those situations intervention preceded cardiac arrest.

3 out of the 4 pulseless codes have been aystole or PEA and those 3 patients died. The only 1 that lived was the shockable ventricular fibrillation: so that is the kind of code I liked best, if “liking” a code were possible.

I am still feeling yucky about the last asystole code. The whole thing keeps playing over in my mind and I keep thinking of how it could have been better. I also can not stop thinking about: this code blue seemed different, maybe because it did not happen on my floor where I work. I was going over to a medical floor to pick the patient up to transfer to telemetry. I  had the feeling that something was not right because the nurse called me in a panic, requesting me to hurry and pick up the patient. While I was en-route 3/4 of the way there I heard the code blue announced to the very place I moving towards and I guessed that it was the patient I was supposed to be picking up.

I walked into the room and the medical nurses were doing chest compressions and nothing else. I am not trying to describe anything negative about the medical floor, I am just trying to express that the other code blues that I have been around on the telemetry floor where I work: the nurses just start working as if being moved by some invisible robotic arm. In fact the other codes on the tele floor that I have seen looks more like:  the defibrillator is hooked up, someone is ventilating till the RT gets there, CPR is performed, someone is checking the line, someone is getting the chart, someone is getting the doppler, someone is calling for an IV pump just in case, someone is recording, someone is printing out the morning labs. It helps that I work on a pretty big floor so there are lots of “someones” around to help. <giggle> And all these someones seem to just announce what they are doing without anyone asking or telling them what to do.  The nurse is telling everyone what is going on and then he/she repeats it all again when the doctor and the ICU nurse arrives.

All I can say is that I would rather see v fib on the monitor than asystole any day. This code was just lifeless, and actually I wonder how long the patient was dead before CPR was started. The latter part depresses me too.

So it makes me think about: I like to bitch and complain about the circus arena that I work in on telemetry. But here is an example of: I wished that patient was coding in my own area called telemetry. I am not intending to claim that the outcome would have been different for the patient, that patient was dead. I am just forming an early opinion that there might be a difference in atmosphere. The outcome for my emotions would be different. I bet I would of felt less hopeless afterwards.

And for me, for my sake who is going to lick my wounds and give me some understanding?

I started this blog in the summer of 2007 when my first patient died in a code 2 weeks off of my orientation. I was sad. It helped me to write my experiences and it still serves the purpose. I feel comforted reading medical and nurse blogs because it helps me to feel not so alone in this thing that we love to do: healthcare.

Nurse Me

12 Jan

I got really sick to my belly

Well what happens when the nurse is sick? Oh what a terrible dilemma had washed over my bowels rendering me a weak attenuated thing. The awfulness can not be underestimated. So how did it start?

Pre viral load day, I felt an aching chill that spread through my body. I sat in the neighbors car for an hour on her heated seat for comfort, it relieved the pain in my ass that I thought was secondary to sitting for a long period studying for PCCN. I never was a good sitter and school used to drive me insane, sitting for lectures equated to one big ouch as I shifted my weight every minute and pumped my calves continuously to the annoyance for sure of all around me.

That night, to weak to cook a meal I consumed pizza and salad from a take out Italian place not to far from my housing. Afterwards I slept without to much of a hitch.

The next morning at 0600 I awoke and groomed myself diligently for the start of a 3 day work spree. I sat on my lowly toilet to pass urine and what came out was diarrhea! I had not felt sick and anyway it was too late to actually call out of work at this point so I trucked into work.

Then at 0800, my first patient, while being assessed by the nice belly doctor asked me about my patient. So I told him the news of liquid stool to which he then asked me: “Will you get me a gown and assist me whilst I perform a rectal exam?” I replied, “Naturally, of course I will assist you dear doctor.” I then proceeded to tie his gown in the back for him nicely and then I moved to opposite side of the bed, leaving the backside for him to assess. What happened next was the good doctor placed his two fingers inside my patients rectum and removed some poop and said, “Nurse the patient is filled with stool and I will have to remove it, can you squeeze some surgical lubrication on my gloved poopy hand.” I said, “Surely anything to make this easier for the patient.” As I thought of what was to come. My imagination behooved me as I stood at the head of the patients bed, gently stroking the hair repeating, “The doctor has to remove the poop that is stuck in your colon and it will be uncomfortable but you will feel better when it is done.”  I felt myself turning green.
My chronic flush fading as I felt the precious warm blood drain from my facial capillaries. I watched the doctor remove pile after pile four fingers wide of poop like bricks that I never thought possible to be stored in one persons colon.
I almost passed out, feeling very syncopal as I discarded the large pile of poop down the toilet in increments of quarter loads to not break the toilet. And then I found myself in the bathroom, somewhat of a wretch with my own gastrointestinal problems in the form of nausea, vomit, and diarrhea. Every patient smell made me want to hurl out the contents of my stomach which was filled at this point with nothing and I felt myself become depleted.
Fluid volume deficit is an understatement as I secretly guess-timated how much volume was lost with each episode. When I finally got home I bet my blood pressure was in the 70s, but I would not dare attempt to measure my pressure, it is bad enough I was mentally mathematically calculating my intake and output.
I crawled into bed with my Gatorade bottles and Tylenol, I was febrile and hurting.
I did not dare take the Immodium because I know whatever was cooking in my intestines did not want to stay there to grow and multiply like some sick fermentation pressure container.
I stayed home from work on day 2 and felt weak but on the road to getting better. I ate toast: the first solid in 40 hours. It did not stay down, it came out the back door. By the evening I tolerated vegetable soup and crackers without immediate expulsion. I went to work for day 3, still feeling weak.
I found myself in charge again and the monitor tech without patients, which was good because I doubt if I could have spinned on telemetry like my usual self. It was still a rough shift and my body was still hurting, it still hurts. My emotions hurt too, but I will save that for another helpless self esteem bashing post another time.
Whatever decided to invade my body achieved its intended effect: to make me cry. Now I feel better enough to seek revenge: I have a big bottle of bleach and a bucket, and I know how to use it. Seek and destroy you nasty poop virus.

forever student

7 Jan

I am not gonna try this!

We never stop learning around here in this business we call healthcare, I guess that is why I like it so much. I get to be a forever student and I do not have to rationalize it to anyone! A few months ago this blogger told me about a procedure demonstrated in the above picture: the precordial thump! At first I hardly believed it although it kinda makes sense I mean a fist can pack some energy. So I looked it up and found some articles and I guess it is used if there is no defibrillator in sight and you witness a cardiac arrest. I doubt that I would ever try it: unless I am in the middle of the desert, or the jungle, or lost in the mountains, and sure that EMS is not going to roll up and rescue and take over; I suppose in those situations I would give it a good whack, I mean thump and hope that I could end a lethal arrhythmia with my fist.   In my pursuit of finding out about this method I also found some other outdated medical procedures such as inserting mercury to break down a bowel obstruction! Read it all here. if you feel like it.  

Anyway it is good to have an open mind and be flexible, or “teachable”. I happen to fit into that teachable flexible type. I want to know if there is a better way, I want to know why we do the things we do as nurses. Things will just get into my mind and I have to know the answer. For example now I find that I am still perplexed over the purpose of infusing half normal saline. I just do not get it and as soon as I finish this post I am going to seek and destroy all useful materials till I find the answer. I guess it is something I should know the rationale for already right? Maybe I just like normal saline because it helps to raise the blood pressure in the sinking, dehydrated, patient. I get jollies from that cause I am a nerd. And because of my fondness for normal saline all other salines can hit the road.

Seriously though, some nurses tend to get stuck in their ways of doing things that they just can not get past any other way. I was told by one experienced nurse who noticed that every week I handling report with one particular night nurse more often than with other night nurses, that it was not healthy because a relationship develops, or you might trust her too much, or things might get missed. This had been planned by me and this night nurse because we worked the same days and it became extremely convenient. Well, I found out that it was true and this nurse has become a nightmare for me, an unhealthy work relationship; I tend to take things personally.  Her anxiety level is so high I am not sure how she handles her job the way she gets so worked up over everything. I try to placate her, but her negativity has striked an all time low lately and I have decided to sever this relationship with her for both of our sakes.  And she also suffers from nurse who thinks she is a doctor and I think that is where all of her angst comes from, that and working on night shift she does not realize that all the physicians have assessed the patient, looked at their labs, adjusted medications, and so on, she just does not see the picture. She starts out every night with negative verbiage like: Am I transfusing blood again? And I respond like, no but if the patient needs a blood transfusion that is your job. And she will greet me in the morning with some negative crap like: Your patients were pooping all night, why did you give this to me? And I respond like, they are “our” patients not “my” patients and sometimes people are sick and poop a lot. Her last meltdown was over the usage of a flat sheet versus a fitted sheet over an air mattress on a patient that has skin breakdown on the back already. Now I am not sure where I learned that a flat sheet is better, I just knew that probably from orientation but it does not really matter in the end really. I advised her if she did not like the sheet that I used she was free to change it. She did not like my response very much and flipped out and even cursed at me telling me to show her the policy and evidence of utilizing a flat sheet. Of course I could come up with no such piece of paper to please her outraged mentation so I just ended the conversation and made sure that every single patient that we had on an air mattress had a flat sheet over it so she could become enraged after I was out the door and in my warm car, to safety.  I did not  flip out on her when she handed me a patient that had an occluded lumen on the PICC line that she was infusing antibiotics via the other lumen when the hospital policy clearly states that the lumen should be cleared before infusing anything. I mentioned it to her briefly that we should tPA the line, and that is what I did after she was gone, spoke with the physician about the occluded lumen and tPAd the line. I do not want to drag this out anymore, I really did get it out of my system last week ranting and raving about her unprofessional behaviour and luckily I obtained the support of colleagues. I just do not want end up like her one day: negative all the time.

I am back to studying for PCCN certification and I applied to a university to start the work for a BSN, I hope to start this semester one class at a time and I have no excuse not to. I am secretly contemplating writing a novel, but this is not the time to show my hidden talents.

Happy late New Year! Maybe some time I will have the time to fix this blog up, it looks kinda plain to me lately.