Friday, December 31, 2010

First night in the Nursery....

So in order to work in Mom/Baby, one must have NRP training in case a baby does something dumb like stop breathing. I'd been asking about getting my certification since I transferred back in September, and was told "Don't worry about it, we'll take care of it."

Until my manager got a call from The Powers That Be who said "If PurpleRN doesn't have her NRP, she'll be suspended without pay until she is." There were no classes available that I could go to, so I got sent home with the manual and a DVD and told to study while I was in Montreal for Xmas.

I then woke up at 0645 so I could be at work at 0800 to do the written test and practice "megacode." Luckily, it only took about 2 hours since it was a class of one :) The instructor said I'd get my NRP card in a week or so.

So imagine my surprise when I'm listed for Nursery duty when I get to work that night. Okay. Can't be that bad, right? Even if I don't have the card, I have the training.

I was blown away by the busyness. At max, I only had 5 babies at a time, but the 3 that stayed most of the night kept me crazy busy.

Started off the night with just one baby while everyone was getting report. Then the littl'uns slowly started trickling in. Nurses just wheelin' them in, saying "Purple, can you do my baby?" and walking back out. Again, I don't get that. It's one thing if you plan on having the baby stay the night; then it's my baby. But I am not a 10-minute oil change place. Or maybe I'm misunderstanding the job.

Then the overnighters started coming in. One nurse had 3 of her babies with me; she felt bad about it lol. So I'm assessing my charges and whatnot, and one of them starts spitting up. Okay, no biggy. Babies do that.

But over the course of the night, she spit up at least 6 times. I couldn't get her to hold formula down (exclusively bottle fed *frownyface*)

You know how crying is contagious with babies? Apparently so is vomiting. At least with my luck that night. When I got baby #1 cleaned and settled, baby #2 started spitting up. Ok. Turn on side, bulb suction. Meanwhile #1 spits up again so I turn and suction and then baby #3 starts. I'm thinking "WTF! I only have 2 hands!"

When the synchronized puking is finally over, someone wheels in a baby and says "This one needs Bili and PKU. Was supposed to be done last night, but lab missed him."

Ok. So drawing from a heelstick is *not* my strong suit. But I gamely put on the heel warmer and gather my supplies, and then spend the next 10 min torturing this tiny soul. Had to milk the leg to keep the blood going, and ended up having to poke him a second time to get the second lab. And while I'm drawing this baby, someone brings another one in for labs as well. I'm thinking "You sure this has to be done now? Can't it wait till 0600 labs come?" Meanwhile the nurse who brought first baby in comes back and wonders why I'm not done yet (cuz I'm bad at this, duh!) and someone recommends keeping the baby under the warmer so the blood flows more easily.

So with 2nd lab baby I fire up the warmer and get my supplies. And I dunno if it was the warmer or this baby had better blood flow but it took *waaaay* less time and the kid barely noticed. And my back hurt way less since the warmer is higher up and requires less hunching over. Body mechanics are not my strong suit.

So lab babies are finished and baby #1 starts throwing up again. I give up trying to feed her, regardless of how hungry she's acting. I look through her chart to figure out why there might be a problem. C-section baby, okay, can be a reason. Then I see a note wherein I discover that at 2 hours of age, the parents gave 25mL formula by bottle. A fresh newborn's stomach capacity is <10mL generally, and the only reason she would have to take in that much formula is if she just kept sucking for comfort...

So I give her some extra time before feeding again, and turns out she is terrible at sucking. All jaw action, no coordinated tongue movement. So at 0600 I finally give her 3mL by syringe, drop by drop under her tongue. She manages to keep it down and finally fall asleep for more than 10 min the first time in the shift.

In addition to baby care, also have to check the emergency equipment and do the Quality Control on the glucometers.

All in all, I think I like Nursery duty all right. I think the best part is that it's more reactionary need-meeting care rather than plan-for-the-shift care. Easier on the brain when you're just playing defense.

I am looking forward to when the rotation lands back on me for Nursery, if only so I can get more practice....

Thursday, December 30, 2010

Why I am not moving to Montreal....

I love visiting my family up in Montreal. There's something about Christmas in that city that feels different from any other. So when I was there last week for the Holidays, I thought about what it would be like to live there.

I've been saving my pennies to buy a house; it's really expensive where I live, to the point of extreme frustration. Yet in Montreal, many of my cousins (some younger than me) are already homeowners. You can get a beautiful brand-new construction there for the price of a fixer-upper here.

So the question came up - Why not move to Montreal? "We really need nurses here!"

But I don't think I could be a nurse anywhere but California. I have never known life before the mandatory patient ratios took effect in 2005. I don't know what I would do with 8 or 10 or 12 patients, apart from lock myself in a bathroom and cry. And to have to keep an eye on a colleague's 8 or 10 or 12 patients when she takes dinner... I can't imagine.

I've never once had to work mandatory overtime. I've had to deal with annoying phone calls begging me to come in on my day off and desperate managers scouring the floors for anyone who wants to stay over. But if I say no, that's it. No repercussions.

I've never shown up and been told to go home because they didn't have enough patients to go around. They will find *something* for me to do around the unit and pay me for it. But I can volunteer for a day off if I want (and I usually do!)

I've never had to float to a unit that I am unprepared for. They can't just send me to Pediatrics out of the blue because they're short staffed; I have to be oriented to and trained for the unit.

I've never had to rotate my sleep schedule to accommodate revolving shifts. If I am hired to Nights, I work Nights. The only time I have to forgo sleep for something work-related is if we have a Skills Day, since those start at 0800 (grumble grumble).

If I had to deal with those situations as a possibly daily occurrence, I don't think I'd make it. Maybe I'm spoiled, who knows. And I suppose the kicker is that if I were to live and work in Montreal, I'd get paid 1/3 to 1/2 what I do here. And the cost of living isn't *that* much cheaper.

So, no, I don't think I'll be relocating any time soon.

Plus, my French skills are dismal.... :)

Sunday, November 28, 2010

This site has the most imaginative pictures!

You must go to the site to see the rest! Super cute and super creative!

(I know this has nothing to do with my work other than it is baby-related, but such is life *grin*)

Saturday, November 27, 2010

Forgot to post this when it happened, but now's as good a time as any...

This is back when I was on Tele (Sept 7), but pretty near the end of my sentence there.

I was Resource, or maybe Committee. Regardless, I didn't have patients of my own. My task was to help discharge a patient who'd been admitted for CHF. I knew pretty much nothing else about him lol.

So the discharge paperwork has a lot of instructions and education on it, so patients don't have to try to remember every little thing. The CHF paperwork is probably our most common; I can quote chunks of it from memory.

So I'm going over the instructions with the patient, his wife, and his son: "Start taking these medications, this one has changed dosage, stop taking this one, etc" Then we get to the lifestyle habits that are essential for controlling CHF.

"Try to cut as much salt out of your diet as possible. Penzey's (a spice company) has some amazing salt-free seasoning mixes that really help make up the flavor. And make sure to weigh yourself every morning, after you pee, but before you eat anything, wearing similar clothes every time." At which point the patient looks rather confused. I said, "Oh. Is this a new diagnosis of CHF? Someone from the CHF team should've come to see you at some point." "No, I got diagnosed last year." "And no one has mentioned weighing yourself?" "I don't even have a scale." Ohhh boy....

So I got to explain how salt and water work to balance in the body, and increased salt makes water stick around longer. It makes the heart work harder to move around the increased volume, and the fluids tend to leak out of the vessels causing swelling in the legs and difficulty breathing. Fluids can build up pretty quickly, so weighing yourself is the best way of telling if things are getting bad. If you gain 2lbs in a day, or 5lbs 5 days, it's likely to be water, not real weight.

"Trust me on this one thing: cutting the salt and checking daily weights are the easiest way to avoid ending up back in the hospital. I *know* you don't wanna come back here. It's much better to catch it early, and just go to the doctor for a med adjustment..."

Apparently no one had explained this to them in the way they could understand, let alone told them *why* they should make these lifestyle changes. I made little extra cheat notes on the instructions to help them remember the basics.

Eventually the runner came to wheel the patient out, and I wished them luck and headed down the hall. The son called me back for a moment, smiled, and said "Thank you so much for all your help, you should at least have dinner on me." He pressed a $20 bill into my hand. I thought about protesting, but he looked so genuinely, sincerely happy that I figured I'd just keep my mouth shut.

I never thought being a nurse would involve getting tips :)

Tuesday, November 2, 2010

In which I am mistaken for a Stepdown nurse...

So I had this patient.... Came into ER with headache and nausea, and BP 200s/100s. 33 weeks pregnant. Stat C Section for pre-eclampsia. I took care of her her first night on the floor. Her SBP was still on the higher side (140s), but coming from Tele that's really nothing to write home about. Baby was in NICU. Mom was recovering fairly well. Sort of. Turns out she developed HELLP syndrome and her blood counts were not pretty. Still, she was pretty stable and seemed to be doing okay.

Then I had her the second night. Apparently during Day and Eve shifts, her kidneys started failing. Her urine output was scant, and she was starting to get a bit swollen. They gave a small dose of IV lasix (20mg) but no luck. By my shift, we were during hourly urine outputs (ugh) and labs q6 hrs. Lungs were starting to get a little diminished, and the slightest bit coarse. She was on nasal cannula and continuous pulse ox, with frequent vitals. Honestly, it was kind of refreshing getting some of what I was used to.

Until I realize that I was not dealing with Med/Surg doctors.

I text-paged the doc to let her know that urine outputs for the various hours was very low (totaling about 70mL for the entire shift) and mentioned the lung sounds. Asked if maybe we try a larger dose of lasix or something (would be the first course of action on tele, since it can sometimes prevent renal failure from worsening). The doc said they'd decided she had Acute Tubular Necrosis and that we should encourage PO fluids and keep the IV running.

Yes, doctor. We should keep pumping fluids into someone who is not processing them or excreting them. That sounds like a great idea. Fast forward to change of shift when we have to cut off her ring to prevent it from impairing circulation in her very swollen hands.

When I came back the third night, I was incredibly relieved to hear she'd been transferred to ICU (apparently there were no available SDU or Tele beds) and set up to start hemodialysis.

She finally recovered enough to get back to the mom/baby floor, and with any luck should be going home this morning. :)

Friday, October 22, 2010

Explaining circumcision

As a Mom/Baby nurse, it's my unfortunate duty to ask parents if they want their boys to be circumcised. The "circ trays" are prepared during the night shift, so we need an accurate count so we can be ready, and the docs know how many need to be done.

I do not believe in the circumcision of infants. I don't believe in doing cosmetic surgery on a person without their consent. So this part of my job kinda sucks.

I found myself in an interesting situation with some parents who were Indian. From what I've seen, most people from India don't circumcise. But these two had no idea what I was talking about; I don't think they'd ever heard the term.

So I tried to explain it as unbiasedly as possible: "Circumcision is the removal of the skin at the tip of the penis for cultural or cosmetic reasons." Nice and simple. And judging by the looks on the parents' faces, completely horrifying.

You could see the question in their eyes. "Why would someone do that?!"

I then went on to say that most Indian parents choose not to circumcise, and they looked relieved and said, "No, I don't think he will be wanting it."

Just another day in the life....

Sunday, October 17, 2010

Quick charting funny....

Reading through the doc's notes last week, and one of them wrote this gem:

"Pt tolerating regular diet, passing flatus and chicken and soup."

I wonder how often people actually proofread their notes for clarity....

Sunday, October 10, 2010

Adventures in my first week flying solo!

I'd originally planned to write this after the first night solo.... and then I decided to make it the whole weekend.... but I got lazy and am only now writing, since is it 6:30am on a Sunday and I am Very Not Tired.

The first night on my own was slightly surreal, I guess. When I started off as a new grad, the orientation seemed to last forever. I might as well be a new grad again when it comes to Mom/Baby skills, but here I got three weeks. Which, all in all, is still pretty nice to get a feel for a place and to hone the skills I hadn't used since nursing school. By the end of orientation, I was actually kind of itching to be on my own, and to stop having someone looking over my shoulder all the time.

The first night, my patient load was split fairly far across the unit. I was a little nervous, because I like having my patients close to each other so I can hang out nearby in case of trouble. But none of my rooms were really near a station, so I just hoped for the best.

Nothing terribly exciting happened that first night, for which I am grateful.

The second night, I got a taste of Tele, just to remind me I guess. One of my patients had had a failed induction, ended up c/s. Had some hemorrhaging afterwards, as well, so I was a little worried it'd start up again.

I guess she was still a little numb from the spinal or something, because when I was assessing her, I found that she... needed some cleanup. It'd been a month since the last time I needed to do incontinence care, and there are no CNAs on this unit. So I take care of all that, which was fun since she had a little trouble moving her legs still.

After I finish, I ask her to let me know if she notices any change in bleeding, including any gushing feelings.... So I get a call about 10 minutes later saying, "Uh, I think there was some gushing...."

Nope. Not blood. Sigh :(

So I clean her up *again* and start feeling like it's that animated video where the patient craps the bed because it's the nurse's job to do pretty much everything. (see video here; the bit in question starts around the 2-min mark)

Luckily, no more code browns that night. Though I did have to deal with missing antibiotics, so that was fun. And at the end of the night/first thing in the morning we got back her post-delivery CBC. Her H&H was something like 7/20.

Now this is something interesting, I find. If one of my patients on Tele had that kind of lab result, I'd be slightly panicking. If it was an 87 year old dialysis patient with CHF and UTI that was CTD, they'd pump a couple of units of blood in ASAP and do serial H&Hs q6 hrs. Apparently if it's a new mom after major abdominal surgery, they prescribe PO Iron, TID. I guess they're the experts, but it seems a little weird to me. I mean, if *that's* not the cutoff for transfusion, what is?

(Apparently I can answer my own question by doing some Googling...)

The next three nights I actually got most of the same patients. One of them had the cutest baby ever. She was born at 37 weeks, c/s early for IUGR and a bad-looking monitoring strip. Mom was pretty young, with twins at home that also had health problems r/t extreme prematurity, and a history of substance abuse with a currently-using boyfriend/FOB. On the second day she kicked him out of the room, and he never came back. Which is very very good. Anyway, this baby was only 2000g at birth, and had tiny little pointed ears like an elf. I could've fit her in my scrub top pocket and taken her home with me. I really hope things go well for her.

I'm finally starting to feel tired now (cuz the Benadryl is kicking in), and I have to get some sleep since I'll be working tonight; I'm very bad at napping, so I should get as much as I can now :)

More adventures to follow, I'm sure....

Monday, September 27, 2010


So last night when I was bored around 0400, I discovered that blogger has a "stats" section for your blog, which includes information on how people discover your page.

There's a section that says what website (mostly google) sent people here, but there's also a part that has what people searched for to find you.

Some of the things make sense:

"does full code mean you don't have an advance directive?"
"food in the lungs"
"can nurses wear converse"

Some of them are cute:

"never send a doctor to do a nurse's job"

But this one just plain baffles me:

"anaisthisia doctor porno"

.....bwah? I would really like to know what person googled that term and found me. I mean, I understand Rule 34 and all that, but who would look that up? Really?

I'll definitely be keeping an eye on my stats from now on... looking forward to future hilarity :)

Thursday, September 23, 2010

Time to compare and contrast!

So I've done 5 shifts on Mom/Baby so far. The first day I shadowed on the floor. The next two I was in the Well-Baby Nursery (shadowing/helping out). Fourth day I took one patient, and the fifth I took two.

So I feel like I'm getting the hang of this place.

The Good

-No more demented old men peeing on my shoes and then asking if I'd get in bed with them! The only poop I have to deal with is meconium, which comes in small amounts and has no smell. Bye bye CDiff!!

-Night shift is very chill. I thought it would be a real issue adjusting to the schedule, but so far so good. I've even got the start of a daily pattern. Get report, do vitals and assess, and then the first cup of coffee (3/4 coffee, 1/4 milk). Then chart and wait for something interesting to happen. Maybe give a pain med here or there. Remind moms to breastfeed, then take "dinner" around 0300 or so. Before 0400 I have my second coffee (1/4 coffee, 3/4 milk) just to keep me going. I've been warned that coffee after 0400 can be detrimental to sleeping when you get home. Then just sit around waiting for something to happen until 0600 pain meds. So far, so good :)

-Management actually cares! The NOC shift ANM comes around every couple hours to do a "wellness check" to make sure the nurses aren't drowning, and that people have gotten their breaks, and to see if anyone needs a hand. Sometimes the ANM did that on Tele, but it was more like, "Why is this med overdue? What's going on? What do you mean you haven't taken your break?" Very different approach lol...

-Management does things to make the unit better. Apparently the nurses were complaining about having to get snacks and ice water for patients, and it would be nice if the patients' families had access to the kitchen. For infection control purposes, the kitchen is code-locked. So the management brought it up with the Powers That Be and they are working on a "family snack station" so people can serve themselves. I didn't even know you *could* complain about having to get food for people. I spent at least an hour each shift running back and forth to the kitchen lol.

-High quality frozen yogurt at the staff meeting. Plus the meeting was interesting and interactive in an organic sort of way, not in the kind of way where your manager calls on you like you're a student and expects you to answer a question like you'd been paying attention. Apparently they do a 2-hour meeting every other month rather than a 1-hour meeting monthly. Saves on the boring lack of news. It went well enough that I didn't mind staying three hours past shift, and that's saying something.

The Bad

-The (perceived?) lack of autonomy. One of my patients had an order for Norco (5/325) q6h around the clock. Makes sense, s/p c-section. So I gave it. The nurse I was working with said "Oh no, you have to verify with the anaesthesiologist first. Look here:" and then showed me on the computer system, where the orders said "No narcotics via IV or IM route for 18 hours after Duramorph. Said nothing about PO. Plus the patient had a stronger PRN Norco (10/325) ordered by anaesthesiology, so obviously it's not contraindicated. Another example: if a patient on Tele has antibiotics ordered, but no continuous fluids running, we set up our own primary line so we can piggyback the various meds without having to start from scratch every time. Standard practice. When the med is done, we run saline long enough to flush the line and then disconnect. No biggy. One of the nurses I was working with actually called the doctor to get an order for a primary line at TKO so she could piggyback the med. If I did that on Tele, the doc would probably yell at me for wasting his/her time with a stupid question.

-Apparently the various medical teams (mainly OBGYN and Anaesthesia) don't talk to each other. One patient had three separate orders for PRN Norco (10/325). That's just *asking* for a mistake, people...

-No CNAs on NOCs (dunno about the other shifts) and there aren't enough dynamaps to go around. People stake them out before even getting report and then treat them like private property; I've seen names labeled on them! But that brings us back to "the good" and that the manager has ordered a few more machines.

The Weird

-People will bring their patients' babies into the nursery, and ask the nurse on duty there to do their assessment and charting on that baby. WTF? I can't even *imagine* asking someone to do that with an adult patient. The assessment is the cornerstone of nursing care, and passing it off to someone else just blows my mind. Vital signs and weight, sure. But I wanna *know* that my baby's lungs are clear and that he has normal heart sounds, not just take someone's word for it.

That's it for now, more stories to follow, I'm sure :)

Saturday, September 11, 2010

Movin' out....

I guess I should start from the beginning.

Once upon a time, Big Shiny Hospital decided that there were some problems with RN staffing, and having enough people at the right times of day. For example, our unit was mixed, having 8 hour and 12 hour nurses. That meant there were shift changes at 0700, 1500, 1900, and 2300. There were times of day where we were understaffed, and people were called in early, and other times where we were overstaffed and people were offered the chance to go home early (which I'd *always* accept lol).

This setup makes for confusion, and poor distribution of nursing resources. So they thought "Why not make everyone 12 hours?" The problem with this idea is that you don't need as many nurses when they work 12 hrs instead of 8, so jobs would be lost. Having the kick-ass Union we do, that was *not* going to happen. So they decided to turn all the units to 8 hrs only, with a couple exceptions like ICU.

Because of the 12 hr jobs going away, positions were being created all over the place. This was an opportunity for my escape.

There are three telemetry units in the hospital, and they decided that two of them would go to 8hrs and one (ours) would go to 12s only. As you are all aware, I wasn't thrilled about working that unit 8 hours, let alone going up to 12.

So I looked into my options. Couldn't go to L&D, because their training program is too long to qualify for a realignment transfer. But lo and behold, Mom/Baby had openings!

Happy people with babies? I'll take it!

They only had night shift (2300-0730) available, but really, I'd do anything to get out. So I put my name down on the list to bid for the job, positions being given by seniority. No one else wanted it, so....

The realignment was supposed to take effect mid-July, with people moving to their new positions then. Mama decided she didn't want to let me go, and got permission from the M/B manager to keep me around a little longer... Well, a lot longer.

Tonight was my last night on Telemetry. It was a pretty standard shift. Nothing notable. People told me they'd miss me, but the unit hadn't been the same since so many other people had already left for greener pastures. I'll miss everyone there, since most of the people were pretty darn cool. But ya gotta take an opportunity when it presents itself.

So here goes. New unit, new shift, new coworkers.... I imagine there will be many adventures to share with you.

I'll keep you all posted :)

Wednesday, September 8, 2010


So in order to transfer to mom/baby I had to get up to speed on the latest and greatest in postpartum information.

Apparently, this means three 8-hour days of watching VHS tapes on breastfeeding from 1994.... I watched more VHS tapes in the last 3 days than the last 3 years. I'm not a morning person to begin with, seeing as I work(ed) swing shift, so getting up at 0800 for a fun-filled day of video watching was nothing short of exhausting.

And I'm honestly not sure that I learned anything, except that the hospital cafes do have pretty decent food. (Yay for grilled portobello with couscous) I read so many nursing blogs and keep up on the latest news about maternity-related issues that I think I could've gotten away with watching maybe half the stuff they had me go through.

But now I am full of knowledge, and ready to hit the floor!

Monday, September 6, 2010

For those of you who were getting concerned....

No, I'm not dead and I haven't fallen off the face of the earth.

I have many half-blogs written, and ideas floating around my head. I just have trouble putting pen to paper (or fingers to keyboard, I suppose).

I've been accepted to transfer to Mom/Baby. I'm finally getting out of Hell. Only four shifts to go, and it's happy people with babies instead of old people dying slowly over many visits.

"I can't wait" doesn't *nearly* convey the excitement here.

I anticipate more stories to come... don't worry :)

Monday, June 14, 2010

A short funny....

I was checking in on a patient. Early 80s, emergency BKA but in remarkably good spirits, cracking lots of jokes. Her grandson (mid-late 30s?) was visiting her and we got to chatting a little bit. Got to hear a story about how the grandson once tore his bicep while moving a bookcase. "It didn't hurt that much... what really bothered me was the wet, ripping sound."

Anyway, I was standing by the door and asked, "So is there anything else you need or anything I can do for you?"

She paused and looked thoughtful for a moment before grinning and saying, "You got any porno flicks?"

Her grandson and I looked at each other and he turned beet red and we both started laughing so hard that people walking down the hall turned to look and see if we were okay.

Even fifteen seconds later you could still hear him laughing halfway across the unit.

I love little old ladies!

Tuesday, June 1, 2010

So Pissed!

I know sometimes doctors make bad decisions. But the same thing happened *twice* in the last week, and I don't want to have to deal with this nonsense!

So on Thursday I get a transfer from our Ortho floor around 1600, right at beginning of shift. The guy had had a fall, broke his tibia, nothing too exciting. He was coming to us for more monitoring, as he'd been having trouble breathing. Now, we can't do anything extra for shortness of breath that they can't do on the regular floor. All we can do is keep continuous watch on his EKG and pulse ox.

So he gets to me, and he's not lookin' too good. Breathing pretty hard, and asks for the bed to be sat all the way up, plus an extra pillow behind his back. I call RT immediately to get him a treatment, because I can hear his wheezing without a stethoscope. I call the doctor, and he decides he's probably fluid overloaded and orders 80mg of Lasix IV, along with a drip.

I'm thinking he's gonna wear out soon enough, with how hard he's breathing. He really should be on a BiPAP, which can't be done on our unit. But we decide to give the Lasix a chance to kick in. One hour later, there's only 75mL of urine in the catheter bag. Not a good sign...

Somehow in the course of all this, the appropriate people for an RRT show up. Not sure how, cuz I didn't call them lol. All of a sudden, orders are popping up all over the place. So we work on getting an ABG and one doctor decides we need to draw labs for starting a heparin drip, because the dyspnea could be caused by a PE which is a known post-op risk.

Before I know it, around 1745, he's headed downstairs to Stepdown. He eventually ended up intubated in ICU for a night. We knew from the moment he got to our floor, that he would end up leaving us very quickly. Why didn't the doctors see it?

Then today, I get report on a patient coming from the Oncology/Medical floor across the hall from us. Came in with pneumonia awhile back, spent some time in ICU, then stepdown, then to the normal floor. Over 90 years old. Family is insane, calling one of our sweetest doctors "the grim reaper" because she brought up the topic of palliative care and hospice. Patient is, of course, full code, and the son cannot be persuaded to change his mind, and becomes hostile at the suggestion.

The nurse giving me report said that the patient looks *bad* and that she will probably end up going to stepdown or ICU in the near future. The RRT nurse who showed up at 330 wrote in her note "Recommend pt go to stepdown." But no, the docs send her to our floor. Where all we can do is watch her struggle for every breath. Even after I tell my manager and he calls the appropriate people.

So she shows up on our floor around 2030, wearing a non-rebreather mask. She's satting 100%, but her RR is 32 and she's using all her strength to keep going. She's able to nod yes/no, and can say maybe 1-2 words. But she's exhausted. I'm thinking "why the hell is she here?"

I call the doc, and stress that she doesn't look good and that maybe she should go to stepdown. The doc says that they are trying to avoid another ICU stay, and she wants to try her here first. She promises a visit in about 45 minutes.

The docs show up, and immediately order an ABG, and put in a transfer request to stepdown. And I'm thinking "Why do you keep wasting my time, and jeopardizing the patient's safety?!"

I give report, and by 2230 she's headed downstairs while I frantically try to get all my charting and notes done by end of shift.

Dear Doctors,

Telemetry is not a magical unit. There are a couple extra heart medications we can give. And we can monitor EKGs and pulse-ox continuously. But in terms of breathing, we are incredibly limited. We can only use CPAP, which doesn't help someone seriously struggling to breath. All we can do is watch and wait and hope things don't get worse.

Therefore, I have a request to make of you. Please. Listen to us. If a nurse suggests that a patient is better suited to another unit, it's not just us trying to get out of taking another patient. We want our patients to be in the safest place.

If you are planning a transfer to higher level of care, and you are debating between two different levels, please, please, please, send the patient to the higher level. Worst case is that they get too much care. People can always be downgraded if they get better. But if a patient is sent to the lower level of care of the two, valuable time is wasted, putting the patient at risk.

I don't want to have to do go through this scenario again. Listen to your nurses, and err on the side of caution. That's all I'm asking.



UPDATE: Within 24 hours after showing up on our unit, the elderly patient transferred from Stepdown to ICU, then was put on comfort care and transferred *back* to 330 where she passed away peacefully. If only they'd just let her *stay* there in the first place...

Saturday, April 24, 2010

This has been a glorious week!

Of the four days I was originally scheduled to work this week, I've only done one and a half.

I was unexpectedly called on Wednesday to see if I wanted the day off. Hell yeah!

On Thursday, I was given the opportunity to go home after 4 hours. Hell yeah!

And today, I called to see if there was any chance they were overstaffed and didn't need me. Ask and ye shall receive!

Thursday was a fuckwad of a hard day. We only had 4 RNs on the floor because our census was low. According to Papa, that means that we technically only need one RN to be both Charge and Break Relief. I dunno if he's ever tried to do both at the same time, but it is *not* safe.

As Charge, you're the one who does the assignments and works with the house supervisor to figure out beds and nurses for incoming and outgoing patients. As Break Relief, you are to take over a nurse's patients during her scheduled breaks, and care for them as if they were your own.

This is nearly impossible when you've go the House Sup calling you every 10 minutes asking if you have a new bed available. Especially when you technically don't have any nurses to take patients yet, but you will after 1900 when the Night crew comes in, so you have to try to plan for the future. Meanwhile one of the patients is desatting to the mid 70s and the alcohol withdrawal pt with a history of seizure is complaining of a headache and needs pain medication. And the calls keep coming in. 84 year old with syncope from ED. Transfer of small bowel obstruction from stepdown. Pt coming from post-op who had an anaesthesia complication.

I dunno what dumbass came up with the rules, but he obviously hasn't ever tried to do 6 things at once, safely, before.

By the time 1900 rolled around, I was ready to throw my phone out the window and rip off the head of the next person who asked *anything* of me. Technically everyone got their breaks, and the assignment did get done (3 times.... every time I thought I was done, I got the call for another pt coming in). But it was more stress than the extra 5% an hour is worth.

When I got today off, I decided not to be a lazy bastard and went on a 9 mile bike ride with my boyfriend. It was awesome. I think my goal is to go on a ride at least 2x/week. One of the girls at work is 3 months pregnant and still skinnier than me... this must be dealt with.

Wish me luck!

Monday, April 5, 2010

Our Easter Miracle....

Today was an aberration to be sure. I woke up at 0700 to go to Easter breakfast at a friend's house. Then I got in trouble at home for missing Easter brunch with the family. There is nothing worse than disappointing my Mom. I was feeling pretty down and guilty when I got to work.

Imagine my surprise when I saw the board: the gods saw fit to reduce our census considerably. We were at 14 (I was kinda pissed off at the beginning, as I'd called to see if I could have the day off and didn't get a call back...) beds filled until near the end of shift when we went alll the way up to 16.

The miracle is that were actually appropriately staffed. More than expected, really. Not only did we have a Charge, I was Resource, and we had *two* CNAs. With only 14 patients lol.

And the RNs on the floor seemed to have everything under control, and most of them refused their 15 min breaks saying they didn't need them. I practically had to beg to take phones away at least so they could do things uninterrupted.

I ended up busying myself cleaning the med rooms and restocking the IV start kits, which were in a horrible state of disarray. Dear Unit: MRSA swabs are not part of the IV start kit. Tele stickers are not part of the IV start kit. Suture removal kits are not part of the IV start kit. Also, urine specimen tubes do not go with the blood draw kit. Just saying... Please try to keep them nice for at least a little while!

I got to take someone down to CT, didn't get lost, had a nice chat with the Radiology Tech downstairs. I figured it would make the most sense just to stick around during the scan rather than go up and have to come back down again later.

There's not much point to this post, I suppose. I hope I get patients tomorrow so I can be in my own little world...

That is, if I can't get the day off... :)

Friday, April 2, 2010

Dear Grateful Patients and Family Members...

We, your nurses, love knowing if you appreciated our care. There is nothing that gives me the warm fuzzies like a little old lady saying, "You're so sweet and caring. Such a wonderful nurse." Makes me forget that I hate my job sometimes.

But I have a favour to ask of you. I know I probably don't speak for the majority, but for myself, I have this tiny request.

Stop it with the baked goods already!!! Why does "I enjoyed your nursing care" automatically have to translate into piles of cakes and cookies in our break room? I'm trying to lose weight for god's sake!!

I can turn down a box of chocolates, or distribute them among coworkers. But I am powerless against homemade lemon squares, or chewy chocolate chip cookies. And nothing goes down quite so nicely after a hard shift like a cup of tea and an almond biscotti that just happens to be sitting on the break room table.

It's instant dopamine gratification, and it needs to stop. You will make me diabetic, I am sure of it.

If you want to show your appreciation, I'd love it if you filled out one of the comment cards we have at the nursing station. My boss sees those, and I need all the good words with her that I can get.



Monday, March 22, 2010

The ugliest rhythm I have seen so far in a person who wasn't actively trying to die...

I had a patient yesterday who was 81 (but looked much much younger) who was A-Fib brady (in the 40s, 30s when sleeping) with a bundle branch block and a long QT interval.

Needless to say, pacer pads were nearby....

Thursday, March 18, 2010

It always happens at shift change, right?

So after a busy but not-too-hectic evening, I finally sat down around 2245 to finish up my charting.

I had a lot to catch up on, because of a new admission to 63. He showed up on the unit around 1800, but was immediately whisked off to dialysis before I had a chance to do any assessment beyond "He's alive, A&Ox3, and doesn't look like he should be in the hospital." He came back to the unit around 2130. I did my admission sheet, got him dinner, and brought him his (late b/c of dialysis) meds in record time, done around 2230. He was doing just fine all through it.

So at 2250 his wife comes up to the desk with a worried look and says, "My husband is not acting normal at all. I need you to come take a look right now." She said it with such calm and straightforwardness that I was immediately terrified. When people come at you with histrionics it's usually something stupid like needing a repositioning. When there's an eerie calm, you know there's trouble.

I popped my head into the room, and he's staring off to his left, with a right-sided facial droop that I didn't recall seeing 20 min earlier when I was last in the room. We asked him to say his name, and his speech was slurred and unintelligible. He was able to lift his left arm on command, and give my hand a good squeeze, but we couldn't get any response from the right hand side. Couldn't even get him to turn his head that direction.

"Well, shit" I thought.

So I called the on-call doc and asked her to get up to us to check him out. Resource came in to check his vitals, which were fine. We decided to call RRT to get a little extra help.

Doc showed up a little before 2300, we called a Stroke Alert about a minute later. This involved doing an assessment on pronator drift, and getting a bunch of blood samples.

The lab had been in not too long before and said he had "slippery" veins. They weren't lying. Luckily, he had an 18g in his forearm with brilliant blood return that we were able to get samples from. Thank god.

He was off the floor and down for a head CT by 2313, which isn't too bad, timing-wise. Things seemed to move much more quickly, and I was always surprised when I looked at my watch.

His poor wife was rather shocked, because this wasn't what she expected at all. Hell, they were going to send him home from ED earlier that day. Got him dressed, took out his IVs, everything. Then they changed their minds and sent him up to us.

So after the CT they sent him to ICU, and I had to wait awhile to give report to the nurse who would take him. Hooray for overtime!

I was told by Pappa that they did find a couple blockages on the CT and he was eligible for tPA.

I'm curious to see how it all ends up when I go back to work today.

Addendum: So apparently they didn't do the tPA after all, owing to the severity of the stroke and how many areas it involved, as well as the fact that the pt was a Jehovah's Witness. If there were bleeding side effects from the tPA, it would be very problematic if he didn't accept transfusions. He is stable now, transferred to our neuro unit, already able to swallow safely and working on his communication skills. Apparently they called an erroneous code blue on him yesterday when he had a seizure post-dialysis. Luckily he's still okay.

Well, okay as can be expected....

Tuesday, March 16, 2010

Forget designer knock-offs.... here's the product I really want to see...

So going back to Hypoglycemia Girl and "I Need My Pills" Lady from a couple posts ago...

At one point during the shift I was chatting with Hypoglycemia Girl and her boyfriend, and had apologized a couple times for not checking in on her more often. I explained (without compromising confidentiality) about the issue with INMP Lady and how I wished there was something I could give her.

HG said, "Can't you just give her something else, like Tylenol, and tell her it's the right stuff?"

I explained that most of our patients (especially the older folks) know their pills by look more than by name or what it does. I said, "I've had patients refuse certain medications because at home they take two little green pills not one pink pill, even though I explain to them it's just a different manufacturer"

Together we came up with a fabulous idea for a business, creating Placebo knockoffs that look just like the real thing. That way if your patient is demanding Ativan but isn't allowed it for whatever reason, you can give the appropriately sized and colored placebo. Of course, they should be kept separate from the full-fledged medication, and be available only in hospitals.

But wouldn't that be damn helpful for confused folks who can't understand that if we give them Ativan when they're already having trouble breathing, they might stop breathing altogether....

I know we shouldn't be out to deceive our patients, and that we should educate where people don't understand. But some people are apparently ineducable and just giving *something* would reduce stress on everyone's part :)

Thursday, March 11, 2010

Dear Hospital Management,

My birthday is coming up in May, and I thought I'd let you know ahead of time what I'd like so you can get working on it.

I would like my unit to be appropriately staffed all the time. I don't want it to be an unexpected surprise when we have two CNAs on the floor, or when I get my 15-minute breaks.

Last night we were dangerously understaffed considering the complexity of our patients. We had all twenty-six beds filled. Three of our patients are worth *at least* the work of two our three patients themselves. We've been good. We are doing our PCHs as diligently as we can.

For a full house, we are supposed to have a Charge, two Resources, and two CNAs on the floor. There was one Resource and one CNA.

This is just plain wrong.

One of my patients last night has CDiff, is incontinent, and has a Stage II pressure ulcer on his coccyx. I cleaned him 5 times in my 8 hour shift. Each time I had to spend *at least* 20 minutes just trying to find someone, anyone, to help me clean him up. That much feces near that severe of an open wound for that long is just *screaming* to brew a massive infection. On top of that, this pt's wife is *very* involved in her husband's hospital stay, and not in the good way. This guy is doing his best for a TTJ and we just keep putting in new corpaks (Don't even get me started on the corpak adventure. Let's just say that after as many X-rays he got, I wouldn't be surprised if he started glowing in the dark.) and turning him every 2 hours and doing dialysis and putting restraints on so he doesn't pull things off.

I spent at least four hours of my eight-hour shift just on him, nevermind my other three patients (two of whom were mentioned in my adventurous last post) who thank god didn't do anything exciting.

So much time could've been saved if there'd been more help around. I had to rush to check on bed alarms because there was no one else. And bed alarms are only effective if there's someone to hear and react, much like the tree falling in the wood.

I know we're going through a lot right now, what with our realignment nonsense. I know you don't want to hire any new outside people until you figure out where all of us inside are going. But just because you're planning for the future doesn't mean you can ignore the present. When you are in the hospital, the present is all you have. If you don't take care of it, you don't have a future to worry about.

So, Management, if you have any shred of love for your faithful employees, you'll give me this one little thing I'm asking for. You still have two months to get it together.

Thanks for your time,


Wednesday, March 10, 2010

Adventures of the day.... I hate adventures.

My day had started off with an adventure in hypoglycemia. Young patient, early 30s, had a gastric bypass a few years back. For the last 2 years, she'd been having issues with hypoglycemia because her pancreas decided to go apeshit at her. She eventually came in because of a loss of consciousness r/t hypoglycemia. The doctors discovered she had reactive hypoglycemia. (Long story short for the non-technical types: person eats a meal, blood sugar increases. Pancreas goes "HOLY SHIT THERE'S SUGAR! ATTAAAAAAACK!" and sends a flood of insulin, dropping the blood sugars like a ton of bricks.) I told her to give me a call the moment she started feeling funny.

So around 1640 I get a call "...ssuugar low. trieddd.. drink juice" and that was it. I experienced an impressive bout of tachycardia and ran to go check on her. She was barely responsive with eyes closed. Checked her sugar on our machine, 56. Apparently she went down to 24 yesterday. I tried to contain my panic as she started twitching uncontrollably and looked for a mobile computer so I could look up the Doctor's number and be able to scan in the Glucagon. Gave the IM Glucagon and waited a little while; she didn't come out of it and continued twitching/jerking. Decided it was time to call RRT to come keep an eye on her for me. When RRT came I took the opportunity to grab another Glucagon (our last one!) from the Pyxis and dose her. Her sugar went up to 118 but she still didn't wake up.

Finally after about 45 minutes she came to, thank god, with a FS of 134. I spent the rest of the shift terrified she'd do it again. Luckily, her sugars stabilized, at least till I went home. Curious to see how she is today.

Then I had a shift-change adventure with a confused patient. She was A&Ox3 at the start of shift, because that's how these things work. The trouble started around 1930 when she started asking for a sleeping pill. I called the doc, and he didn't order any because of her recent stint with intubation in the ICU (good call!) and wanted to make sure her respiratory status was good before worrying about sedatives. But the patient didn't let it go. Every time I went in the room she demanded her pills. I explained what was going on and why she couldn't have her normal sleeper, but she didn't understand. She kept asking me to go to the middle bedroom and get the little pill bottle out of the bedside table. Her daughter even tried to reorient her, and we took a short walk out of the room to show her the hospital hallway. No luck.

Eventually we agreed that we'd just turn out her lights, give her earplugs, and hope that she settled down enough (after not sleeping for 2 nights) to pass out. Her son was staying the night, and with any luck he'd keep her calm.

So come shift change, I get rung at by the tele monitor saying that her HR was steadily climbing. 120s, "okay, she's AFib, it happens." 130s, "hm this is weird". 160s "holy shit let's see what's going on."

So I run down the hallway and go in the room to find her legs out of the bed, and her lying at an awkward diagonal. I ask her where she's going and she said "I fell." For a moment I freaked out because patient falls are a huge issue. Then I thought to myself, if she ended up on the floor, there's *no way* she's strong enough to get back in the bed like this. She's a moderate assist just to stand from sitting. So I assist her to sit at the edge of the bed, and the bed alarm went off. Okay, so the bed alarm was armed (I'm pretty obsessive about the bed alarm now) and functional, so if she had fallen out of bed, it would've rung before.

I look at her, and notice she's very upset and teary eyed. I asked if maybe she had a bad dream in which she fell. Lord knows we've all had that awful "tripping off the edge of the sidewalk" dream and then jerking awake slightly freaked out. She said that she had, and that she needed to use the commode. The oncoming nurse and I helped her to the commode and I stood by while she attempted to go (with no success). We helped her back into bed, and she continued on about getting her pills.

Meanwhile her son in the pull-out bed lifted his head a few times, but at no point did he attempt to help us reorient his mother. What's the point of spending the night if you're not going to be useful?! It's not like it's fun or comfortable staying in the hospital. Help out or go home...

Anyway, we get her settled and comfortable, turn the bed alarm back on, and I went home. I look forward to reading the night's notes...

I can't wait to get off the Tele floor. It's a spirit-crushing, down-heartening hell-hole lots of nights. Makes you sad for the elderly and pissed off at the family who thinks that death can be prevented indefinitely. We all have to die someday, and we all have to die of something. Why torture people in the interim?

Monday, March 8, 2010

Step one in solving our healthcare crisis...

Let's reduce the price of diagnostic supplies. Imagine a slip of paper the size of your fingernail that can tell you if you have HIV, Hep C, or TB. Medical technology is frickin' awesome!

Thursday, March 4, 2010

A quick laugh

Everyone gets a kick out of less-than-savory medical abbreviations (like GOMER: get outta my ER) but somehow I'd never heard this one.

WNL = We Never Looked

Short, sweet, and totally true half the time lol

PS: here are a couple more lists of funny abbreviations. I am particularly a fan of CTD (Circling The Drain), LOL (Little Old Lady), and TTJ (Transfer To Jesus - which I wish more of my patients would do).

Tuesday, February 23, 2010

I'm still hoping for my TriCorder...

but these wireless innovations seem pretty damn cool. I especially like the "smart bandaids." Definitely worth watching.

Monday, February 22, 2010

Dear Patient in 63,

I know it sucks being in pain and being stuck in the hospital. However, using your call light literally (and I do mean literally; I kept track) at least once every two minutes will *not* increase your level of care. You seem alert and oriented, so we're assuming it's not that you're confused, you're just insane. When you call that frequently, especially for things you can do yourself, we start ignoring you like the boy who cried wolf. I don't care how much your shoulder hurts; if you can reach the call light that often you can reposition your arm a couple inches to make yourself more comfortable.

Ma'am, if you behave today like you did yesterday, I am going to take the call light away from you and read you the Riot Act like nobody's business. We have 25 other people on our unit, and 95% of them are in more serious condition than you are. You are jeopardizing their health by monopolizing our time and attention.

Knock it the fuck off!

Purple RN

(After she whined "I'm just so miserable!" for the umpteenth time, I did say "Ma'am, we're *all* in the hospital and we're *all* miserable." She laughed a little, which I suppose is better than calling my manager...)

In my perfect world, I would invent a call light with a built in electric shock. If you use the call light more often than, say, 20 times in an hour, you get zapped every time you hit the button after that. I think it would encourage much more judicious use of the call light, and in an emergency situation I think a person would withstand a little zap to get real help. Until they perfect the Ativan mist or Ativan nebulizer treatment

Monday, February 15, 2010

A compliment a day does wonders for the self-esteem...

"You're a nurse." She said it in a somewhat awestruck way, as if it were something she hadn't encountered yet during her 4 days of hospitalization. She was in her mid 80s, here for sepsis and trouble with breathing. Standard-issue patient on our floor.

"Um, I try to be..." I said confusedly, worried that she was sundowning.

"No, I mean it. You're a real nurse. No one has done that for me the entire time I've been here." I was busy tidying up her bed, and untangling the phone and call light cords while she sat on the commode after finishing her business. "Huh? Fix your bed up?"

"No. Cleaned me."

I had just come to help her off the commode, and I noticed some old soiled toilet paper stuck to her backside, and various other substances that needed addressing. So I got a warm washcloth and some soap and gave her backside a decent scrubbing while she balanced holding onto my other arm and shoulder. Really basic nursing school stuff. Patient is dirty? Clean her up.

I was a little shocked to hear it, so I clarified. "No one has helped you clean up after the bathroom since you got here?" "Nope," she replied. "Yesterday I called for help and no one came for 45 minutes. I was watching the clock"

I apologized profusely on behalf of whatever nurse was responsible for that incredible lack of care. Personally, if I can't be there to help my patient within 5 minutes, I send someone else. And if that person can't be there, I will make myself un-busy to help (barring an emergency situation, of course).

"Don't worry about it honey. You're doing a great job, and you're a wonderful nurse. Thank you."

It made my day. And the next few days, I got compliments from patients and family members each day.

"You're a good nurse."
"I'm glad I have you as my nurse again."
"You're kind and efficient. You're good at what you do."

One of my friends recently commented that the way I write this blog, it sounds as if my job always sucks. I told him that the shitty things make for better stories. No one wants to hear, "I did my assessments, passed my medications, charted, wrote a couple notes, and made sure my patients were comfortable." Crazy people and wacky adventures are where it's at.

But when something good and uplifting does happen, dammit I'm gonna share it :)

Thursday, February 4, 2010

First day back after a week off...

It was a hell of a week off (family emergency/drama), not relaxing in the slightest, and my first day back was a fucking doozy.

The central issue was a young (<65 is young on my unit) man who had melena in the morning and came to ED to get checked out. He went for an EGD on his way up to our unit, and got to us right at the start of shift. Upon arrival, we found out that the room he was slated for had not yet been cleaned (previous occupant was out 6 hrs prior) but was listed as clean. So my patient is hanging out in the hall, not looking one bit sick. His H&H was 13/37.9, probably better than anyone else on the unit including mine lol.

He flags me down and asks if there's a charge nurse he can speak to. I ask what the problem is and he says that after the EGD, they told him they didn't find any active bleeding. He said that he couldn't afford to spend the night in the hospital, and that his copays had doubled recently. I told him that we'd need to get a doctor up to the floor to discuss the issue with him, and that if they decided on it, he could leave AMA.

The room gets finished, he hangs out in there, and the doc comes to talk to him. Meanwhile, I avoid releasing any orders, just in case he decides not to stay.

Apparently the doc figured that if he took one of the meds PO instead of IV, they could keep him here for observation instead of admission, thus bypassing the cost of a hospital admission. Everyone was happy. Yay. I do my new-patient questionnaire, get his orders going, and things go smoothly for awhile. (At least with this patient. One of my other ones had hospital-induced loss of hand function. Could always reach the call light, but not pour her own damn drink)

So I go off to dinner feeling pretty positive about things. Nice easy patient.

I come back from dinner and find Resource Ninja and one of the other RNs in my patient's room. Apparently while I was gone, he threw up 200mL of blood. They put in a large-size NG tube, and sucked another 500mL out of his stomach. They were total rockstars. They drew labs, started 2 new large-bore IVs, and got an NGT inserted in like 5 minutes. The doc decided to start him on some IV drips, and get him sent to stepdown for more acute care and a stat EGD.

We seemed to have a completely full house. Trying to figure out the bed issue with the boss-man was a nightmare. First I hear we have a bed in stepdown, but we have to take one of their patients in exchange. Then we don't have that bed and there are no other available beds. So I get told he's going to ICU. I call ICU to try to give report, and they have no idea who this person is. I find out I was given the wrong room number and that he's going to a different ICU. Make up your fucking minds people!!!

I go to check on him while I let the management figure out where he's going. Poor guy threw up again. It looked like cherry pie filling. Huge globs of coagulated blood that had no chance of going through the NGT. The pt had been sitting on the edge of the bed, so he could vomit more comfortably. However, with this new advance, and the slowly increasing amount of blood in the suction canister, I decided he'd be best off lying back in the bed just in case of passing out.

I go out to the station, finally find out where my patient is going, and give report as they're wheeling him down the hall on the bed. I could hear him arrive on the other end of the phone. The portable monitor's PING is unmistakable.

I finish up my notes (though it occurs to me now I forgot to chart the hematemesis on the I&Os) and try to catch up on everyone else. Later on I find out that he has a huge gastric varix that somehow got missed the first time, or just decided to open up while I was at dinner.

The best part is that the very next day, right at the beginning of shift, I'm told I have an admission. "He's easy" they said. "It's just a GI bleed, and he's a walky-talky. Nothing too exciting." Never been so terrified of that diagnosis before...

Wednesday, January 20, 2010

I wish the BBC would allow embedding of video

You must go watch this video. It's about an outdoor maternity "hospital" and the nurses who are trying to help out. I wish I was down there. I have a year of almost-critical-care under my belt and put my name on the Registered Nurse Response Network list. You can donate at to help fund much-needed supplies.

Anyway, here's the video