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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   In my pursuit of finding out about this method I also found some other outdated medical procedures such as inserting mercury to break down a bowel obstruction!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.

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Rage against the ME

9 Dec

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

7 Dec

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.

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.

Burned out neurons

13 Sep

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.

Amaryl

6 Jul

I  remember this eccentric endocrine MD who when consulted on patients in the hospital for either high or low blood sugars. He would come in, look at the chart, see the patient on Amaryl, see the trend of blood sugars dropping below 50 and flip out in the nurses station about Amaryl and Kidney function and how patients with increased creatinine should not even be on Amaryl– in fact he was so adamant that NO patient in the hospital should be on Amaryl. There are just to many variables affecting the blood glucose of sick patients, especially decreased kidney function as we load many of the patients with antibiotics and lasix and CT scan dye (not to mention the NPO status half of the time for testing)!

I thought at first he was just out-of-the-box, eccentric, passionate, teaching nurses in ways that seemed to me way over my head as I tried to understand his lectures, but really felt lost. The bottom line is that I remembered and learned : No AMARYL for impaired renal function and extreme caution if the attending family doctor is ordering amaryl in any of my patients.

So today here we go……. internal medicine doctor admits patient 5 days ago to tele. Cardio on consult for severe CHF, patient getting massive doses of lasix, BUN and Creat are rising and rising daily. Patient is taking the Amaryl. ooooooooops here we go….blood glucose 27–nurse gives an amp of  dextrose–glucose goes up an hour later to 57–it is not enough! nurse calls internal medicine doctor and asks for IV fluids D10—MD says “No, I never have this problem at the nursing home but every time my patients are hospitalized you nurses are always calling me about this–feed the patient!” Nurse says that the patient is 90 years old and does not want to eat. Finally the MD “gives” in to D5%1/2 NSS at 100ml hour. Nurse is upset because the patient is in the hospital for CHF! Nurse is getting upset. Q 1 hour blood sugars are taken and the patients blood sugar is still below 60 and keeps dropping! Finally the nurse at her wits ends calls the House MD and a rapid response to treat the hypoglycemic cool, sweaty, confused patient and the patient gets the appropriate treatment. The patient  had to transfer to ICU for q1 hour blood sugar checks and all the while I am thinking, ” This could of been avoided if the AMARYL was never ordered!”

Patient Advocacy: If you are not getting the treatment you need for your patient you have to go elsewhere.

I tried to look for a quick article on Amaryl and renal impairment and could not find one yet, but it does not matter: I SEE this happening again and again! I even heard it could take 3 days to get the medication out of the system if the kidneys are impaired so if your patient has a poor appetite, in kidney failure, and in the hospital: Don’t give the Amaryl! I would rather give the insulin with meals and chase the coverage then to go through that again!

No more nitro for you

2 Jun

nitroDear Patient,

You have been in PCU for 2 weeks. You have had a 2dECHO, an ECG every day, continuous rhythm strip monitoring, blood pressure  checks every 4 hours times 24 hours for the past 2 weeks. You are on 3 liters of oxygen at home and in the hospital even though I checked you on room air your saturation was 96%. You have had a CT of the head, chest, abdomen and pelvis: all negative. You have had ultrasounds of all four extremities all negative for blood clots. You move your bowels everyday. Your urine output is adequate. Your lungs are clear. Your heart sounds S1 and S2 with the absence of S3, no murmers, rubs, or clicks. There is no neck vein distention and no edema anywhere (fat tissue is not edema).  You have positive pedal pulses palpable even after your heart catheterization which revealed nice clean coronaries.  You have upper GI series with small bowel follow through: normal. Of course you had an EGD and a colonoscopy: normal.

I have six patients of which you are one, although that is not really your problem. It is my problem, considering, one patient in end-stage  heart failure, one is in respiratory distress on and off the biPAP, one is confused and keeps ripping out IVs and bleeding all over the place and one is probably septic.

So I am sorry that I refuse to give you sublingual nitro anymore that keeps me in the room for lengthy periods of time reassessing your pain, your blood pressure and another stat ECG. Especially since you then turn around and eat a huge lunch that consists of a saltless hospital food burger and fries. And I realized after 3 consecutive shifts with you that it does not matter if I give you nitro, maalox, tylenol, or any other PRN medication that you have on board: they all work the same for you. It is the placebo effect of getting something that takes away your pain so I refuse to keep slipping that small little sublingual pill called nitro under your tongue!

The Maalox  and Xanex work just as good lonely patient: I am sorry I can not just hang out with you all day, because you never seem to have chest pain when I am in your room listening to you complain about how you just do not know what is wrong with you.

And even though you did not mind the huge work up that you just went through last admission (one month ago) that was all repeated this admission:  I am sorry that you have an internal medicine doctor and a zillion specialty consults that can not figure out your real problem. I get this feeling you do not want to go home for some reason: and I feel sad for you.  If you could just tell me what is going on maybe with the help of the social worker we can find out why you want to stay here. All this invasive expensive testing is a hazard to your health.

Love,

Your Nurse

Disclaimer: I am a firm believer in the fact that lengthy stays in the hospital with no identify-able acute illness is hazardous to ones health.  I am not burned out from patient care. I love my job. I do find irritation from time to time when I am super busy with acutely ill patients that need/demand my presence and prescribed interventions and feel overwhelmed by patients that need/demand emotional support but are otherwise healthy and figured out the best way to get the nurse in the room is to put on the call bell and express chest pain 10 out of 10: even as you enter the room and find: the patient in no distress, not short of breath, skin warm and dry: cardiac markers negative time 30 sets, no ecg changes and a totally benign assessment. So you do the whole chest pain work up routine again and it sucks up all your time and inside you find yourself angsty worrying about your other sick patients. And this repeats every 2 hours. I would love to be able to provide emotional support but unfortunately: airway breathing and circulation on my other sick patients left me with little time for this particular situation.