Tag Archives: ICU

The Invisible Nurse

26 Feb

The invisible nurse that reports for duty when short staffed. 

 

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.

As the tele pack turns

8 Sep

Telemetry packs often look like this. We hook those wires up to patients and can see at the nurses station a continuous reading of heart rhythms and some even have blood pressure monitors as an added bonus. tele pack

Speaking of ICU nurses before I describe my last shift I want to mention a great blog post that introduced me to Nurse Sean: the post that summarized exactly how I was feeling at exactly the same time can be found here and the blog is here. Nurse Sean has been in my sidebar for awhile now and honestly I stopped clicking on his name for awhile but it appears that he is writing and I am clicking and reading.

Sometimes as a telemetry nurse things get crazy. Some of the patients are on the cusp of being critically ill while some are apparently stable, with unstable angina seemingly on the stable range of the shooting field. Some are admitted honestly by MDs to telemetry because we take blood pressures every four hours and they feel that the patient is closer monitored even if they do not need continuous rhythm strip analysis.

Resources. Working in a community hospital resources are a precious commodity to me, a telemetry nurse. And that is why I felt guilty after my last shift. I got report from the night nurse that a patient was admitted from the emergency department after going to the doctors office for being “shocked” multiple times within the last few weeks by his internal defibrillator: after interrogation it appeared the patient was having sustained ventricular tachycardia hence the AICD was doing its job. Anyway he arrives to the floor with a systolic pressure in the sixties. The night nurse gives a 250ml normal saline fluid bolus bringing him up to systolic in the seventies. I check his labs and see that his creat doubled since yesterday, and of course I was concerned. I assess the patient who is completely awake and orientated, only complaint was “a little dizzy” and his pressure is again in the sixties. The patient appeared to be in no distress at all: no pain, no tachycardia, no shortness of breath, clear lungs, making urine,  just a “little dizzy”.

Every nurse on telemetry it seems is so afraid to run in fluids: mostly because more than half our patients are in heart failure or have a history of it. Every nurse who has seen their patient go from breathing just fine to acute pulmonary edema will know the fluids can be frightening: but giving a dizzy patient with a blood pressure in the sixties only 250ml of fluids and calling it a night is not quite right!

So here I am on day shift with the maximum nurse to patient ratio of 1:6 ( a crime). Tending to this patient giving multiple 250ml fluid bolus over an over again (slipping in a little extra here and there)  when I really just wanted to run in the whole liter in an hour. Wasting my time doing the whole sepsis workup when internally I felt that the patient was just dry: but I was not willing to risk that assessment alone. When at the end of the liter going in (in 250 increments) the patient was finally transferred to ICU for the inability to maintain a decent pressure in spite of a liter of fluids: with scheduled anti-arrhythmic  medications to prevent further ventricular tachycardia that would lead to another “shock.”

Needless to say the patient received another liter in ICU: and was transferred back to telemetry the next day with a normalized pressure, and guess what? BUN and creat back to normal! and no other problems.

I honestly felt guilty like I misused a valuable ICU bed for some gentle fluid resuscitation. But in the end the guilt goes away because to many times, the call is not made early leading to poor outcomes. And to many times in community the ICU bed is not available, and transfers into ICU are actually triaged for the sickest to go in first while the other less sick patients ( but still critically ill) stay or get transferred in to telemetry waiting. When that happens the shift becomes a circus riot and your stable patients hardly see you.

So the census is back to normal. The revolving door to telemetry is open for monitoring. I started my last shift with 6 patients. 2 went home, 1 went to a medical floor, 3 stayed with me, 1 admission from the emergency room and transferred to ICU before shift change and 1 was stepped-down from ICU into telemetry: and that was just my assignment, my group: the story repeats for every nurse that shift and we call it: as the tele pack turns.

Asking for Help

23 Mar

Who you work with on any given shift sometimes can make your day better or crack your twelve hours to pieces when you when you find your assignment in crisis.

I walked in on day one to crisis #1 in respiratory distress admitted to the floor by night shift RN who got ABGs and the patient on bipap but um….5 hours later I walk into this (the bipap is not helping) and the patient is getting tired with a breaths per minute greater than 40 who needs immediate intubation.  And I am stressed out but somehow managed to be calm and I even surprised myself with how clearly I “knew” how to do what I needed to do, restraints, suction, versed….very different scenario 2 years ago when I could barely find my voice in a crisis and just wished I could blend into the wall and let someone else figure it out and speak for me. I have to add that I had the awesome st respiratory therapist by my side, the calmest critical care nurse across from me, the loves to teach physician  keeping it all in perspective, as well as all the other helpful staff.

I walked into day #2 with a blood pressure in the 60s Systolic, clearly septic, on no antibiotics, and platelets count of 19 also struggling to breath and I knew and I felt sad. Blood was everywhere.

I walked into day #3 with a  patient made npo in the night, diabetic on insulin and pills with a blood sugar of 30 and no IV access due to infiltration and no palpable vein in site or touch. I learned that the glucagonIM works in about twenty minutes.  

The insanity is that I felt the adrenaline and I kind of liked it although of course it is a paradox as I would never wish that to be the norm. I think I am gearing myself towards emergency nursing or maybe intensive care at some point, sooner or later.

So the fake seizure in room #2 was annoying, but I regress.

Picture this: I am in the nurses station, the ICU RN has taken care of my intubated patient on day 1 while waiting for a bed to be available on the unit. I am officially relieved of my major responsibility for the patient and nurse A says to me all super loud, “You always get the worst group with sickest patients!” I am still trying to piece together what just happened so fast and my 4 other patients have not seen me except for my quick morning assessments and not one patient has been medicated.  Nurse B gangs in and starts chiming the same tune and I am thinking what fresh hell is this? Nurse C starts ringing in with her sympathy for me and I lose my temper! They sounded like a bunch of cackling hens pecking at me…their morning bird food. So I flipped out and demanded the cacklers get out on the floor and start medicating my stable patients so I can catch up.

It worked! They scurried out and passed all my morning medications. I was able to assess my patients and spend ions charting in detail the crisis and all the interventions provided.