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...