The Nurse in Purple Converse

C-Section Rates at my hospital

2012-01-24T14:12:00.001-08:00

It's been something I've been thinking about for awhile. What exactly *is* our C/S rate, and why are they being done? So I started writing down the stats this week on the nights I work. I'll update it every so often, till I get maybe a month's worth of data. We'll see.

1/18/12
C/S: Primary - 1 (Fetal Intolerance to Labor)
Repeat - 1

Vag: Spontaneous - 4
Assisted - 0

1/19/12
C/S: Primary - 2 (Failure to Progress. Twins)
Repeat - 0

Vag: Spontaneous - 3
Assisted - 1 (Vacuum)

1/23/12
C/S: Primary - 3 (Non-Reassuring Fetal Heart Tones/Code C. Breech. Fibroids)
Repeat - 1

Vag: Spontanous - 6 (one VBAC)
Assisted - 0

1/24/12
C/S: Primary - 6 (FTP/Failed elective induction. Decels/Failed Vacuum. FITL/IUGR. Breech. AOD/Failed elective induction. NRFHT/Post-dates.
Repeat - 2

Vag: Spontaneous - 7
Assisted - 1 (Vacuum)

So far we're at 42%. Granted, we are a hospital that specializes in high-risk pregnancies, but that still seems a little high....

It's here! Hooray!

2011-10-31T14:08:00.000-07:00

50 Things Your Nurse Won't Tell You

Two of my ideas made it into the list, so that's pretty cool. I liked hearing what the other nurses came up with. So true, so true...

It was a very interesting process being included in a magazine, especially when the fact-checker called to see what my opinion was of what some of the other people said, like fudging the dosing on pain medication to keep your patient comfortable.

Quick moment of horror...

2011-09-16T23:04:00.000-07:00

So there's going to be a sympathy strike in our region coming up, and the administration is trying to figure out how to cope with a few thousand nurses missing.

One of the things our Chief Nursing Officer said they'd do was "perform a few extra C-sections on the weekend before" so there would be fewer people delivering on Strike Day.

Talk about unnecessarean....

A short illustration of the difference between Mom/Baby and Telemetry.

2011-07-22T07:58:00.000-07:00

While assessing a new admission, you notice a set of shallow, scabbed-over scratches on your patient's calf. You ask the patient the story behind them, and you are informed that the patient's cat was bad about retracting its claws when it wanted to climb up her leg to sit on her lap.

On Telemetry, this short exchange is immediately followed by you writing a nursing note mentioning the scratches, as well as charting it in the flowsheet. You get the camera out to document that the patient arrived with said scratches, and so you can have a basis for comparison should they change. You upload the pictures to the system in case someone needs wound care to see them. You also write an incident report, to CYA in case someone tries to say that they were incurred on the unit. You waste a fair amount of your shift.

On Mom/Baby, this short exchange is immediately followed by you extending your sympathies and sharing your own cat-related-injury stories. You and your patient share a laugh. You move on with your day.

I do not understand some people....

2011-07-17T18:00:00.000-07:00

Here in my state, you have the right to refuse any and all treatments offered to you or your children in the hospital. I don't know if it's a universal/federal deal, but it is how it is here.

So last night, I had the interesting experience of taking care of a set of brand new parents who refused everything. I mean everything. Mom was not tested for GBS (a bacteria that can cause fatal sepsis in the newborn), hepatitis (which can also be passed on during delivery) or rubella (which can cause mental retardation), which are all standard parts of prenatal care.

They also refused ultrasounds on the baby, except to determine gender. Because dad had read somewhere that the sound waves can cause developmental delays. Based on a study done on the cell division in mice. Having done some googling, it looks like the study itself admits that there is need for further investigation, and that they themselves cannot formally correlate anything to human babies. They finally agreed to one when the mom's fundal height at 34 weeks didn't correlate with the baby's age, which is a sign of IUGR, just to make sure the baby wasn't severely undersized.

While in labor, according to the notes, mom wanted IV pain medication, but didn't want an IV in place. Sorry hon, but they are not going to inject directly into a vein every time you need some fentanyl. Multiple breaks in the skin are just asking for infection risk. Or you'd look like a heroin addict.

When the baby is born, they refuse the "eyes and thighs," which means erythromycin eye ointment, a Vitamin K shot, and the Hep B vaccine. Ok. Here's my beef with this particular issue. I understand refusing the eye ointment if you are certain that mom does not have any dangerous vaginal bacteria (like GBS). I'm totally fine with that. But since they refused GBS testing, and GBS can cause blindness, it seems like a foolhardy risk to take. If they'd tested mom for GBS and she was negative, sure. Skip the eye goo. I'm not sure why they refused the Vitamin K. Probably to avoid the baby being poked. Again, it's their right to refuse things, but the baby had a rather large cephalohematoma. I would be *so* worried about continued bleeding into the space because of lack of clotting factors. And of course, the vaccine refusal was related to autism risks. Don't even get me started.

They refused the jaundice test. They said if the baby turns yellow, they'll just put it in the sun for awhile. She's a small baby, not eating very well, with a hematoma. Jaundice can cause brain damage if it's untreated, and this baby had so many of the risk factors for it.

They also refused the newborn screening which tests for treatable but possibly fatal metabolic and endocrine diseases, like the inability to digest milk sugar. Wouldn't you want to know if your baby could get brain damaged by breastfeeding?!

In addition they refused the hearing screening. I guess also because of dad's fear of sound waves? This is the most benign test we do. We put squishy rubber headphones on the baby and little sticky wires on the forehead and measure what the brain does in response to sound. It takes 15 min and the baby stays asleep through the whole thing.

I guess the thing that baffles me about all this, is why bother coming to the hospital in the first place if you don't want anything the hospital provides? I will defend people's right to make their own choices in medical care, but it would be *nice* if they were based on reality and sound scientific fact rather than "shit I read on the internet."

When you come to the hospital armed with information from Dr Google, while categorically refuting everything an actual MD tells you, it does not look good for you as a rational human being.

And when your stubbornness could impact the health of your baby.... ooooh not good. I just hope that the things they take for granted (the baby won't get an eye infection, the baby's hearing is just fine, the baby doesn't have any metabolic disorders, the baby will not become jaundiced) end up being true. They have a really sweet baby.

But for me, it seems so bizarre to refuse testing/treatment on the remote chance they may cause problems, when the chances are fare more likely that refusing these things will lead to problems.

It would be like spending all your money on alien-proofing your home, while neglecting to put locks on the doors. Sure, there's a *possibility* that ETs will invade your house, but it's far more likely that someone will waltz right in and steal your TV.

New dads are great....

2011-06-20T15:49:00.000-07:00

Last night was a fairly strange shift for me. I was on committee for most of it, to finish up some computer-based training. Then I hung out in the nursery to help out a little, because we had 4 babies under bili lights and one on the blanket. It's too much for one nurse to handle, especially when they're screaming at the same time.

Around 0530, I finally took an admission, and then another around 0630.

The latter one was a c/section, first baby. Mom, understandably, not moving around a whole lot. I got them settled, and told them to call me if they needed any help. At 0700, when I'm giving shift report, I go into the room with the oncoming nurse.

I see a light on in the bathroom, hear water running, and don't see the baby's crib anywhere. I poke my head in the bathroom, and dad is trying to change the diaper.

He has obviously never changed a diaper before. He's wearing gloves (cute! lol), wiping haphazardly. He's trying to dodge the baby's kicking feet, which have poop on them. There is poop everywhere.

I try to suppress a grin as I ask him if this is his first-ever diaper change, and if he needs some help.

I clean the baby's feet, and show him how to do the one-handed grip to keep them from spreading the mess. He didn't set up any wipes ahead of time, so pretty much I started from scratch trying to explain the process.

He told me he didn't want to call for help because he knew he'd have to be able to do it when he got home. I told him that we are there to teach, and that our job is to make sure they can take care of the baby:
"You can do it by trial and error if you want, but it's generally easier to just learn from someone who's already made the errors...."

Awww. gush

2011-06-19T08:30:00.001-07:00

I've been taking care of a particular family for 4 nights now, and they've been through a lot (mainly jaundice/bili lights hell).

Last night they bought ice cream for the unit. Really sweet of them. I am a sucker for ice cream. It's always cool when patients give us snacky-things.

But tonight was the first time I've had a letter written to me. The dad handed it to me, in an envelope made of a sheet of printer paper held together with paper tape lol.

Dear PurpleRN,

Thanks for all the care, support and guidance that you extended during the most anxious and memorable time. We truly appreciate your dedication

- [family]

I'm feeling super good right now. It's a nice thought to fall asleep to.

Gah. Circumcision rant again.

2011-06-17T19:39:00.000-07:00

So I had this unfortunate baby yesterday that was born by vacuum-assisted C-section after a failed vacuum-assisted vaginal delivery. Apparently he got good and stuck.

After a vacuum delivery, it's pretty common for the baby to have a good-sized circle of bruise on the head (like a giant hickey) where the suction cup was placed.

This poor kid had actual scabbing and exudate (ie, "goo) on his head around the edges of the bruise. I'm guessing they tried too hard with the vacuum and broke the skin.

So naturally, the kid is kinda grumpy and fussy. His head hurts.

Then the parents decide to get him circ'd. This poor baby was inconsolable. I would be two if I was hurting from both ends. I wish someone would've tried to convince them to at least wait until his head was healed up a bit.

I ended up calling the NICU on-call doc to beg for a tylenol order for the kid. He was finally able to sleep for a whole hour and a half at least. That's all the sleep he got during my 8 hour shift. And they only gave a one-time order :(

Then I had some parents last night who asked about getting their son snipped and when they should do it. My brain immediately went "Never!" but I told them that if they can wait 24 hours until he has a chance to improve breastfeeding, it'd go better for them. Mom's a c-section, she'll be here a couple days. No skin off their back.

And then I go to change the kid's diaper. Poor thing has a mostly-buried penis. I think if they get him snipped, there won't be much of anything left! We'll see how things are when I go back tonight, if they've done it or not yet.... Mom seemed a little on the fence about it. Fingers crossed for them.

According to the latest data, only ~35% of West Coast babies are circ'd now ( http://www.cirp.org/library/statistics/USA/ ). It'd be nice if we could get it a little lower...

50 Things Your Nurse Won't Tell You....

2011-06-13T11:14:00.000-07:00

I was contacted recently by a writer for Reader's Digest who was putting together one of their famous "50 things" lists. She found me through a comment I posted to one of Head Nurse's blogs ( http://head-nurse.blogspot.com/2011/04/last-minute-request-for-minions.html ) back in April.

Apparently she liked my quip, "I may not decide whether or not you need an injection, but I do decide the gauge of the needle involved..." and decided to ask for some more ideas for the project.

I won't share any of them here, of course. That would ruin the article.

But the request got me thinking. It was actually really hard to come up with good "sound bites" within the topic, because, as a nurse, I live for telling my patients things.

Nurses are educators and advocates, and one of the keys to our job is keeping our patients well-informed. Communication skills are right up there with "how to take vital signs" in the list of important things we need to do.

So I answered the topic more along the lines of "Things Your Nurse Wishes You Knew" or "Things Your Nurse Wishes She Could Tell You" with a bit of a twist in the wording.

I'm very curious to see how the article comes out.

Also curious what my readers (all 4 of you lol) would write for this topic? Anything you really wish your patients knew? Or that you'd never tell them?

A short happy :)

2011-06-09T08:10:00.000-07:00

This happened a couple weeks ago, but I just remembered it and it made me smile.

[Setting - almost end of shift]

Patient: Will my next nurse be as nice and helpful as you?
Me: [laugh and grin] Nope. I'm the best one here! All the others are terrible!
Patient: You really are the best one here. I hope you're coming back again tomorrow.

Makes a girl feel good at the end of the day....

[I would *never* actually downsell my colleagues. I work with an amazing bunch of nurses! It's really nice that we have each others' backs, and we always try to upsell the oncoming shift when we do handoff in the room]

A short rant about communication skills.

2011-04-23T17:42:00.000-07:00

In a hospital setting, good communication is crucial. It can literally be a life or death issue. And even in the cases where it is not, a lack of communication can seriously Fuck Up Your Night.

Last night I was assigned to work in the Overflow Unit, a section of rooms in Pediatrics where we put the Moms that don't fit on the main unit.

I was originally assigned 3 patients, but one of them was halfway out the door. I just had to finish the last of the discharge paperwork and snip off the baby's security tag. Okay, cool. Down to two.

The Break Relief nurse told me to get Room X ready, because I was going to get the next admission. Didn't tell me the name, or when she delivered. I had to do some sleuthing and guess-work to figure out who was the next likely candidate. Okay, fine. It happens.

Then I get a call from L&D asking if Room Y was clean for my new admission. I explained that X was clean and ready, because that's what I'd been told to set up. She said "Right, pt A is going into room X, but she's not ready yet. Pt B is going into room Y." Huh? Who is pt B? "Also, make sure room Z is clean as well." (apparently for the other nurse on overflow with me).

So we scramble to get Y ready, and call housekeeping to clean Z (where I'd DC'd my other patient from). I'm trying to read up on my incoming patients when all of a sudden I see the room number for incoming-patient-B switch from L&D to the Main Floor, not Overflow as expected. Huh?

Apparently one that *they* were expecting was not doing well, and being kept in L&D longer, so they decided to move my patient to the main unit and give me the next one that came along.

It's 0445 when Patient A shows up, strangely lacking her baby. Apparently he was cold and they kept him under the warmers for a bit? Her husband was strange, maybe Asperger's? Obsessed with taking photos ("the lighting in here is terrible, and the white sheets are washing out the picture") while mom was clearly exhausted. Got her settled (the other nurse's patient came in while this was happening) and finally got to go on my break at 0520.

Back from break at 0550, got a 10-minute head's up, and then my New Patient B came to the floor. Did I mention I had 6am meds to give on practically everyone? Got B settled, managed to pass my meds mostly on time and waited for the Day Shift to arrive and rescue me.

And not *once* did my Charge call us to let us know what was going on. I had to call her. I understand what it's like to be busy as Charge. I used to do it on Tele. It sucks when you've got admits on all sides. But I made *sure* to call my nurses and let them know "You've got Mr Smith coming in, he's going into room 1234" as soon as I figured it out. There is nothing more unsettling to me than getting a call from the other unit going "Is the room ready?" and you having to ask "Which room and for what patient?"

I cannot handle not being kept in the loop. And I know that the Charge Nurse knows that this stuff is going on; she's the one making the decisions about who goes where. She changes the information on the L&D "Chalkboard" on the computer, but I am not sitting in front of that screen all shift waiting for information to pop up.

It is *not* that hard to call me and say "Miss Jones delivered at 0100, she'll be going into room 4321" It takes 30 seconds, and makes my night run sooooo much smoother. I know it's doable.

Apparently word got to the Charge that I was not happy, and at the end of shift I got an apology/excuse but no reassurance that it won't happen again.

Looking at what I've just wrote, I realize this is not a short rant. It is a long rant, and for that I am sorry. I just value thorough communication :)

An overheard conversation....

2011-04-11T21:59:00.001-07:00

As a fix for our staffing problems, the management has decided to cross-train L&D nurses to float to Mom/Baby if we are short. One of those L&D RNs was having her first orientation day on the unit. Our scene finds us sitting at the station; they are discussing the pertinent info for shift report, and I am charting about 10 feet away.

[a muffled scream filters down the hallway]

L&D RN: Um, what was that?
MB RN: Sounds like a natural childbirth to me. *grins*
L&D: You guys can hear that all the way down here....?
MB: Yep. Especially if it's one of the rooms at the end of our hallway here.
L&D: [looks concerned] We had no idea you guys could hear things over here. I'll make sure to close the doors next time I have a mom without an epidural.

I dunno why but this brief exchange made me giggle like crazy.

I may have a problem....

2011-04-07T23:00:00.000-07:00

Ok, so this might be kind of stupid.... I'm watching through all of Xena right now on Netflix, and I'm on the last episode of season one. One of the side characters is in labor, spending most of her time sitting off on the sidelines while the main action is occurring.

Cut to her lying on her back with her legs bent, and another character is telling her that the baby "hasn't come down at all" and I'm thinking, "Dammit, woman! You're an Amazon! Get off your back! You're better than this!" (also, since when did ancient greek warlords know anything about childbirth?)

And then they determine that the baby (apparently a half-centaur!) is breech and she has to have a C-section using candle-related hypnosis as a method of anaesthesia and the baby that comes out could *not* have fit inside that woman and then I realized I need to stop taking things so seriously.....

A quick story

2011-03-23T20:16:00.000-07:00

Was helping out with a procedure on the Mom/Baby Unit that involved the pt getting a little bit of fentanyl beforehand to help chill her out beforehand.

I don't know exactly how it came up, but the other nurse I was working with said something about the doctor having to give it. I dunno, I guess we don't give fentanyl on our unit? *shrug*

So I do the doc a favor and draw it up using a cannula access needle
and put the plastic covering back on to keep sterility while we got everything else together.

The doc comes in and pulls the plastic cap off, exposing the red-hubbed blunt needle and asks (confusedly) "So, um, I just put this into the IV?"

I take the syringe away from her and put the plastic cap on so I can unscrew the access needle. "No, it's a needle-less system. Just screw the syringe into the luer-lock on the IV"

She turns to the patient and tries to figure out how they go together (without even alcohol wiping the IV port!). "Um, I don't usually give medications......"

"How about I give the med and we'll just say you did, okay?"

"Sounds good to me."

I don't think this incident is limited to this one particular doctor. My guess is that most wouldn't know how to give an IV med if you asked them to. Which is why my blood boils when I see doctors doing nursing jobs on shows like House.... If it were realistic, they'd have no clue.

Party Pitfalls....

2011-03-23T19:46:00.000-07:00

Beyond, "Can I get a little help in here?!" there is only one other phrase that strikes terror in the hearts of nurses everywhere:

"You should talk to PurpleRN. She's a nurse!"

I was at a party this past weekend and heard the words careen out of a friend's mouth, hitting my good-time-spirit like lead weights. Before I had the chance to avoid eye contact and slip away, I was pulled into the conversation.

Friend: "This guy here is afraid of having surgery."

Me: "Oh? What surgery are you having?"

Guy: "I'm not having surgery."

Me: "Um.... okay..... Then how did this come up?"

Friend: "Tell her about your brother."

Guy: "When my brother was a kid, he had appendicitis and had to have emergency surgery cuz it burst"

Me: "Uh huh....."

G: "So now I'm really worried I'll get appendicitis and have to have surgery."

Me: (Why am I talking to this guy instead of having fun? *sigh*) "I'm guessing he had stomach pains for a few days and your parents didn't take him seriously until it was too late. Generally appendices don't burst without warning.

G: "Yeah, I do remember that happening."

At this point I hoped that our conversation was over, but for the next 20 or so minutes (felt like F O R E V E R) I had to reassure him that no, he was not likely to get appendicitis, that it was even less likely it would burst, educated him about "rebound tenderness" as a classic sign, told him that *if* he had appendicitis and it wasn't an emergency, he could likely request a spinal block rather than general anaesthesia if that was one of his concerns for surgery (at which point I had to explain what a spinal block was...) and I think I'm *finally* done with this guy when he asks again "So you don't think I'll get appendicitis?"

"No. It's not very likely. Judging by your hair color (it was grey) I'd say if you were concerned about something happening to your intestines, I'd get a colon cancer screening."

"People with grey hair are more likely to get colon cancer?"

[facepalm] "......no. You're supposed to get a scope done at age 50 to check for colon cancer."

"Ohhhh.... so you think I'm going to get colon cancer?"

At this point I was interrupted by someone wanting to know if I'd like a drink.

Yes. Yes I did.

Back..... to Telemetry!

2011-03-02T19:03:00.000-08:00

I was briefly excited when I didn't see my name on the census board. "You're not on my list...." said the Charge. Took a brief look at the list from Staffing, and handwritten off to the side was "PurpleRN - Telemetry."

Good thing I just renewed my ACLS.

As you may recall, my old unit converted to 12hr shifts, so I'd be coming to them a full 4 hours after everyone else started. Apparently I was to take over the patient load of one of my no-longer-new grad comrades. As far as a first assignment after such a long break, I lucked out.

There were two alert CHFers, a new admission (that had just been done by the previous RN) who was super fun and talkative, and only one confused fall risk patient.

It was hard remembering all the stuff I was supposed to do for the shift. Totally forgot about all those stupid skin notes and turning notes. Still good at identifying rhythm strips at least.

They got new Dynamaps, which totally threw me off. You have to take them out of standby mode and respond to prompts on a screen, which is very weird.

The most interesting/annoying new thing is a different style of bed alarm. It looks like and it works by clipping a tether to the patient, and attaching the magnet at the other end to a contact point on the pager-type-thing. And it is only effective if the tether is, say, adjusted short enough so that it rings if the patient sits up. If it is long enough for the patient to get to the edge of the bed without alarming, it's not good....

This pt had been given Zyprexa before bed, with the intention of knocking her out. It did a great job, and I managed not to wake her up until I had to around 0530 for a vital sign check and BP meds. I hadn't noticed how long her tether was, as she was more or less sleeping on it.

The alarm went off around 0600, and two RNs managed to catch her before she slid off the side of the bed. The pt thought she had to go meet her husband. Tried to reorient her (with minimal success) and readjusted the lead. Also set the main bed alarm again.

I forgot how much fun that part was.

All in all, though, it was a pretty good experience going back. And it was hilarious seeing people's surprise when they realized I was working there.

Update on the last post I made....

2011-02-21T07:35:00.000-08:00

I would not have thought it possible, but miracles do happen.

She survived.

We got more details of the ordeal after she was transferred to ICU. Apparently she developed abdominal compartment syndrome and had to be opened stem to stern to relieve the pressure. Someone manually massaged her heart while they had her open. They had to wait >24hrs before closing her back up because it took so long to stabilize her.

And yet she made it. With no major neurological deficits. There was some issue with her placement in the hospital after she no longer needed ICU-level care. They transferred her straight back to us, because they were not quite honest about her condition. Normally we don't take care of practically-immobile full-care patients with 3 abdominal drains. She shoulda gone to Tele or something at least. It's hard to turn a patient every 2 hours when you don't have any CNAs on your unit, and the House Supervisor isn't willing to budge....

But she made enough progress that 2 weeks after the ordeal, she's going home. I know there will be some drama for awhile, because no one goes through that sort of trauma unscathed. Especially since her family didn't tell her what really happened to her (it's a cultural thing) after the delivery.

Regardless, I wish her and her family the best of luck.

The rumors came in hushed tones at first, as they often do....

2011-02-07T08:11:00.000-08:00

As if speaking them more loudly would make them truer. Which we all hoped would not happen. The first of them came when the baby was wheeled, alone, into the nursery.

"I heard the mom lost 6 litres of blood."
"They're going to have to do a hysterectomy."

Then even more quietly.... "They say she might not make it......"

Whenever there's an emergency with a mom in L&D, they bring the baby to our nursery so that everyone, including dad, can focus on mom for awhile. We became more concerned when dad showed up in the nursery to visit.

He had so many questions, a wide-eyed first-time father. To us seasoned vets, some of the questions were funny:
"How often does a baby poop? Every 3 hours?" "Well, you can't really predict that...."

Some were strange: "Did he cry when you fed him?" "Do you mean did he cry before because he was hungry, or during the feeding?" "During the feeding." "...No... he was pretty happy about it."

And then there was an overhead page. "Code Blue. Labor and Delivery. OR"

You could practically feel everyone in the unit's hearts collectively stop.

Dad then asked the question that we all hoped he wouldn't: "What does Code Blue mean?"

The break nurse and I exchanged a brief glance of panic, before I gently said, "It means there's an Emergency." I didn't want to tell him the truth. The dad said, "It's probably my wife. There were some problems after the delivery." The break nurse suggested that he go back to L&D to check in, but he stayed in the nursery for an agonizingly long minute or two before finally leaving.

The mood on the unit was funereal and somber. You could see the prayers on peoples' faces.

Another overhead page, specifying that a certain doctor come STAT. One nurse turned to me and said "I hope she's not gone."

Down the hallway we see a doctor and a security officer talking with dad. You can't hear from so far away, but you can only imagine the conversation. Dad looks like a small, lost little boy, with his hands clasped tightly in front of his chest, as if he's trying to keep his heart from falling out and shattering on the floor.

A doctor/nurse/tech (didn't see his name tag) in green scrubs came by to offer some information to our charge nurse. "We lost her pulse twice. They're working on getting her to the ICU. We poured so much blood into her, but it all kept just coming right back out. We didn't even get to finish stitching her back up all the way"

I was in the hallway when they wheeled the mom towards the elevators. A sea of green scrubs like waves carrying the bed along, with a person kneeling at the head of the bed, rhythmically pumping the ambu-bag while someone else followed, carrying the bed's headboard.

The person in the bed looked like an intubated wax mannequin, no signs of life whatsoever, and a horrible damp sheen over the unreal ashen skin.

Another doc came by the nursing station and uttered the most terrifying acronym in the maternity world: DIC. The body uses up all its clotting capabilities and just bleeds and bleeds and bleeds and there's not a lot you can do about it.

The last of the information comes from the janitorial staff. "They say she was fine for the first hour and a half, and was holding her baby. Then after that she started having problems."

"It took us two and a half hours to clean up all the blood."

I know I don't have a huge blog readership, but if any of you out there reading this could spare a moment, I'm sure prayers/happy thoughts/good vibes would be greatly appreciated by the family, even if they don't know it's happening.

First night in the Nursery....

2010-12-31T17:42:00.000-08:00

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....

Why I am not moving to Montreal....

2010-12-30T14:12:00.000-08:00

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.... :)

This site has the most imaginative pictures!

2010-11-28T20:38:00.000-08:00

http://www.fubiz.net/2010/07/27/milas-daydreams/

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*)

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

2010-11-27T17:05:00.001-08:00

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 :)

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

2010-11-02T09:05:00.000-07:00

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. :)

Explaining circumcision

2010-10-22T16:46:00.001-07:00

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....

Quick charting funny....

2010-10-17T17:47:00.000-07:00

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....

Adventures in my first week flying solo!

2010-10-10T18:43:00.001-07:00

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....

Huh....

2010-09-27T14:49:00.000-07:00

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 :)

Time to compare and contrast!

2010-09-23T22:26:00.000-07:00

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 :)

Movin' out....

2010-09-11T23:59:00.000-07:00

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 :)

Training...

2010-09-08T18:12:00.000-07:00

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!

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

2010-09-06T11:35:00.000-07:00

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 :)

A short funny....

2010-06-14T16:10:00.001-07:00

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!

So Pissed!

2010-06-01T00:36:00.001-07:00

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.

Thanks,

PurpleRN

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...

This has been a glorious week!

2010-04-24T20:23:00.000-07:00

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!

Our Easter Miracle....

2010-04-05T00:36:00.001-07:00

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... :)

Dear Grateful Patients and Family Members...

2010-04-02T13:26:00.000-07:00

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.

Thanks,

PurpleRN

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

2010-03-22T13:51:00.000-07:00

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....

It always happens at shift change, right?

2010-03-18T13:37:00.000-07:00

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....

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

2010-03-16T20:12:00.000-07:00

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 :)

Dear Hospital Management,

2010-03-11T17:34:00.000-08:00

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,

PurpleRN

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

2010-03-10T13:15:00.000-08:00

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?

Step one in solving our healthcare crisis...

2010-03-08T02:07:00.000-08:00

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!

http://www.inhabitat.com/2010/03/05/stamp-sized-paper-chip-diagnoses-diseases-for-just-a-penny/

A quick laugh

2010-03-04T13:04:00.000-08:00

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).

I'm still hoping for my TriCorder...

2010-02-23T12:42:00.000-08:00

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

Dear Patient in 63,

2010-02-22T12:32:00.000-08:00

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!

Sincerely,
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

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

2010-02-15T23:21:00.000-08:00

"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 :)

First day back after a week off...

2010-02-04T02:12:00.000-08:00

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...

I wish the BBC would allow embedding of video

2010-01-20T12:01:00.000-08:00

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 www.sendanurse.org to help fund much-needed supplies.

Anyway, here's the video

http://news.bbc.co.uk/2/hi/americas/8471326.stm

Today I got the punishment for something that was not my fault.

2009-12-31T01:45:00.000-08:00

I got a patient yesterday from ICU. Meningitis, had a rough time of it but was pulling through. Very sweet lady who was an L&D nurse for over 20 years. Her family was at the bedside, a little anxious but generally kind and friendly. I joked around with her sons, we made each other laugh. They even gave me a recommendation for a local Middle Eastern restaurant with excellent food and low prices. Things were going swimmingly.

I was excited to have her as a patient again today. But there should have been alarm bells early on in the shift when the pt and her friend (another retired RN) asked when she was going to be moved to the other unit.

Now, I hadn't heard anything in report about a downgrade to Med/Surg, or an upgrade to Stepdown, so I said "I don't think you're going anywhere." Then I got busy enough with the start of shift that I pushed it to the side for a little while.

Then at about 1630 I got a phone call from the manager of our sister unit, who is covering for our manager while she's on vacation. She said that my pt was going to be transferred to her unit as part of a "customer service recovery" issue.

I couldn't get many details, but the gist was that the family was unhappy with her care on our unit during the NOC and AM shifts. The AM shift RN told me that one of the sons was grumpy with her, but I didn't think much of it since he has sort of a sarcastic sense of humour.

I can't imagine anyone being so upset that they request a whole new unit. Plenty of people request not to have certain RNs again, and we're very accommodating to that. But to change floors?

The manager of the other unit said "The family is happy with you. Don't worry about it too much" but wouldn't give me more than that.

So a little time passed, and the family showed up to help the pt get to the other unit. I knew it was bad when the manager was personally escorting the patient. Her son asked if he could fill out one of our "above and beyond" cards about me (we'll see if it happens; it'd be my first one!), and said that he emailed people saying that he was glad to have my care. He even asked if I could get transferred with the pt or if she could stay through the end of my shift.

So one of my best patients gets taken away from me for something other people did/didn't do. It sucked, and I was furious. But my anger doubled when about 15 min later I learned that since I now had an opening (the only free spot), I was getting a new admission from ER.

Luckily it was a pretty easy pneumonia case, walky-talky A&Ox4. Sweet older guy. Thank god.

The worst part about all this is that our unit looks bad. We've spent a lot of energy trying to get the unit's reputation out of the mud, and this is just one more stone weighing us down. "Look at Tele! People are begging to get transferred out!" When our manager comes back, we won't hear the end of it for awhile.

I hope the patient continues to recover well, and that something like this never happens again.

2009-12-06T23:55:00.000-08:00

One of my patients was put on comfort care today, about 2 hrs before my shift started. They had called RRT on her for non-responsiveness and trouble breathing. When I got her, she was on the CPAP and pretty much nothing else.

I tried to be as comforting and supportive to the family as possible. I think I was doing a pretty good job of it.

Until ED started wanting to send people up, and we had no nurses to take them. Since comfort care doesn't require tele monitoring, she was to be moved to the next unit over.

The family was *not* happy.

I apologized profusely, and tried to explain that I was needed to take a patient who required monitoring. Really, there's no good/nice/easy way of saying "We need you out so someone else can come in." No matter how lightly you try to put it, you sound like an asshole.

So I asked the family to try to get their things together, as there were a lot of them there with a lot of stuff.

I saw the bedside table get shoved angrily out the door into the hall. There were a lot of reddened eyes and scowls. I assured them that the transfer would be quick and painless. One of the sons was concerned about her breathing, so I hooked her up to the portable O2.

Things were not made better when we got to her new room and there was no O2 hookup in the wall. I had to run down the hallway and steal one from an empty room. More glares.

I tried the best I could, and still felt like a jerk. I hate feeling like I have no control. I tried to ignore the guilty feeling so I could continue with my shift.

Then about an hour or so later, the two sons came to the unit looking for me.

They apologized for being so harsh. It really made my day, because I was not looking forward to trying to sleep tonight with a guilty feeling.

I hope all goes well for them, and that the patient's transition is peaceful.

I love that old people seem to lose their filters...

2009-11-30T21:33:00.000-08:00

89 year old female, here for GI bleed. Tarry stools. Lots of fun. Anyway, the CNA and I were doing some cleanup.

The CNA had soaked a bunch of washcloths in rather warm water, and squeezed them out over her crotch to help get off some stool.

My patient says, "Oooh. That feels nice. I haven't had anything that hot down there in ages!"

It was all the CNA and I could do not to dissolve into giggles.

Argh. Stupid House...

2009-11-27T09:26:00.000-08:00

Episode "Teamwork"

Chase hangs a piggyback but uses the blue extension hook on the piggy, not the primary. It's never going to go in, jackass. Maybe that's why your treatments don't work! Never send a doctor to do a nurse's job....

Never gets old, does it? Kinda makes you wanna... break into song?

2009-11-20T02:28:00.001-08:00

I love sundowners
I love the bed alarms
I love old gentlemen
And their eccentric charms
I love telemetry
And its adventures

Boom de yada
Boom de yada
Boom de yada
Boom de yada

I love the C-Diff
I love the GI Bleed
I love CHF
Even COPD
I love telemetry
And all its smells and sounds

Boom de yada
Boom de yada
Boom de yada
Boom de yada

I love AV blocks
I love my rhythm strips
I love new A-fib
And starting heparin drips
I love telemetry
My job is pretty cool...

Boom de yada
Boom de yada
Boom de yada
Boom de yada.....

(copyright by me. written after watching one-too-many youtube videos)

Readers!! I need your feedback, as I'm torn on the very last line. Should it be "my job is pretty cool" or "my job is killing me"? The latter is (much) more accurate, but I was actually thinking of making a video for it that management could someday see...

The V-Fib came out of nowhere....

2009-11-11T23:59:00.000-08:00

It had been a slightly rough start to the shift. I found out I had two patients with behavioural issues on either side of the station. Luckily my ETOH W/D had a sitter, but the other one did not.

She was under 50, but had had a recent stroke. Until a couple days ago, there had been no residual. But then she stopped being able to perform ADLs, and her husband brought her in. Now she was agitated, trying to crawl out of bed, and almost nonverbal. Plus she mostly only spoke a foreign dialect that only one of our CNAs (the one who was supposed to be siting with my ETOH) knew, so he was in there trying to keep her calm.

The offgoing nurse let me know that she'd gotten haldol a couple times his shift, and he saved a X1 ativan for me. A little before 1600, the ANM said that now might be a good time to give the ativan so the CNA could go sit with my other patient. Within 10 minutes she was calm and sleepy, all systems normal.

The MDs were concerned about her having seizures because of the location/type of brain damage she suffered, so we started her on dilantin.

I went to go print my strips. She was normal sinus rhythm. I turned to say hi to a nearby doctor, then turned back to the monitor to finish the strips. All of a sudden, V-Fib. For a split second I thought "This can't be real" so I went to go check on her.

There were 2 nurses outside her door, about to go in and do a skin check (THANK YOU GUYS SO MUCH FOR BEING THERE FOR ME!!! YOU ARE AMAZING NURSES!!!) They saw the look on my face when I went into the room, and followed me.

She was slumped over in the bed. It almost looked like an absence seizure or a stroke. Her tongue was protruding, and she was making blubbing noises. We sat her up a little more, did a shake and shout, sternal rubbing, checked for pulse. I had almost hit the code button when she took a deep gasping breath. We felt a moment of relief before we realized that she was probably not going to be taking another breath.

I hit the code button and we started CPR.

From that point, it's a blur of people and activity. Within 10 seconds there were at least 20 people in the room. It felt completely unreal. Like I was trapped in a TV hospital drama, except this was my patient.

I remember people hooking her up to the defibrillator. She was in Torsades de Pointes. The MD yelling for Mag, which was *not* in the cart where it should have been. Finally they bring another tray and we get the Mag for him.

We stop the dilantin infusion, start NS running full blast. Put a compression sleeve on the bag to make it go faster. Starting a central line. CPR still going, intubation in process. Everyone clear for the defibrillator. Still no pulse, CPR continues. I try to clear debris off the floor so no one slips. There is packaging everywhere. Another shock. I took over for chest compressions for awhile. More feeling of unrealness. Drugs are going in. Triple lumen central line in place in the groin. One of the docs stitching the line down to the thigh. That must hurt, I thought, then remembered my ACLS instructor saying "It doesn't matter what you do in the code. The person is dead and not feeling a whole lot" The MD forgetting to let go of the guide wire before the next shock until another doc told him to drop it. Shock again.

The pulse came back. I go give report to ICU who has a bed for her. She's on the unit even before I finish giving report.

From hitting the button to sending her to ICU was around 30-35 minutes. Part of me feels like it lasted so much longer than that. Part of me feels like it was over so fast. I totally forgot I had other patients. It was probably the most in-the-moment I've ever felt. It was also probably the most disconnected from reality I've ever felt as well.

The ANM congratulated us on doing a good job. I was certain I'd get in trouble or something. I must have done *something* wrong to make this happen. Turns out she had an MI related to an LAD blockage. Not my fault. Thank god.

I was pretty shaken so I took dinner early. Went to the garden near L&D. They have lavender and rosemary growing there. I laid on a bench, listened to some music on my phone, watched the clouds, and tried to will my heart rate to go down below 100.

I can no longer boast about never having a patient code on me. But I no longer have to fear it eventually happening. And that's probably the better of the two options.

Sigh. I had hoped she would recover...

2009-11-03T23:47:00.000-08:00

I posted about a girl with lung cancer back in June. She and her friends got me dinner from Jack in the Box when I forgot mine. Everything seemed so bright and hopeful when she was finally discharged.

Today while heading out of the break room I noticed a new magnet on the fridge.

"In Loving Memory, P*, *1981-June 14, 2009" with what appeared to be her Senior Photo in the middle.

Really bummed me out on my way home. She was such a sweetheart. And yet the 85 yr old non-compliant CHFers just keep ticking. Stupid world.

New syringe design makes re-use impossible

2009-10-27T13:37:00.001-07:00

I'm glad people like Marc Koska exist... Truly brilliant

Man I love children...

2009-10-25T22:28:00.000-07:00

At work last week a dad came up to the back station with his two kids (8ish and 12ish?). Their mom was on our unit, and the kids were understandably worried. The dad wanted to help reassure the kids, as well as see how his wife was doing.

He asked if the kids could take a look at the telemetry monitor at the desk. I said sure and brought up the appropriate strip window and turned the screen towards the kids.

It was a picture-perfect sinus rhythm, 60-62. I didn't know the patient, so I don't know if that's on the brady side for her or what, but it looked fine to me. I asked if either of them had seen something like this before, and the older one said it looked like in movies. I said that the heart runs on electricity, like a machine, and the bumps were little jolts of electricity. "When the heart gets shocked, it squeezes up tight, just like when you get a static shock and you feel yourself twitch a little bit" I pointed out the QRS complex: "This point here is what tells the heart to beat. See how everything is very smooth, and the bump (P wave) is nice and round, and the spike (QRS) is thin and pointy? Those are all good signs of a healthy heart."

The kids looked a little relieved, as did the dad, I think. lol I brought up another strip, with had a fairly jagged baseline, the occasional missing P wave, and huge blocky QRSs. I pointed out how different it looked from their mom's. Hers was just plain prettier to look at.

Then I told them about the monitor techs in the cockpit looking after her heart, and the phones we carry calling us automatically if something bad happens "but something bad won't happen" interjected the dad. I hope he's right. The dad thanked me for explaining things to them. I told him it was probably the best thing that happened for me all week.

I really enjoyed the interaction. I miss young people a lot. I miss being able to educate people who have open minds and vivid enough imagination to make sense of what I'm telling them. I need to get the hell out of telemetry.

Spotted this on Nurse In Australia's blog. Had to share....

2009-10-21T00:40:00.000-07:00

Be warned, the injection techniques are somewhat scary. What licensed person would even *think* of doing it like this?

Had an odd, yet very good, shift this evening

2009-10-21T00:00:00.000-07:00

When I got my assignment at 1500, I was a little concerned. One of my pts was going to cath, and not coming back. One was to be discharged ASAP, as the family was getting antsy. This would leave me with two spaces for admissions. Wheee!

So I got my two out of there as soon as I could. While I was trying to get ducks in a row for my DC, I get a text from monitor tech saying that one of my pt's leads was off. So I go into the room, and my pt is practically dancing out the door, tele box on the bed. I ask her what's up, and she said "The doctor said I can go home!" "Well that's all well and good, but we prefer if you tell the nurses before you start tearing off equipment." She laughed and apologized, and I went to go see if there was a discharge order. Sure enough, in the space it took me to go see her and get back to the station, there was a new order. Okeydokey, I thought. Why not just let another one go...

Did the DC in record time. I was down to one patient by 1630 or so. And my last patient was a young walky-talky who came in for ACS, and had been chest pain free since the morning. Pretty much just here for Lovenox to thin his blood so they could try to avoid another cath (he'd had one in July).

So I was the best damn nurse I could be to my one patient. I also helped 2 other nurses pass meds. Frankly, I was bored lol. I was told I'd be getting an admission, but by 1830, no one called to give report. The Charge and I did the math, and figured that I could go on committee and give my pt to one of the incoming RNs at 1900.

When on committee, you're supposed to do audits and paperwork. I ended up being more Resource-like (as I always do) because it helps the unit far more than all the paperwork in the world. I got to help orient one of our new traveling RNs, a nurse who'd been on the job since I was in kindergarten. I know it's hard getting used to a new hospital with a new system, but she seemed extra frazzled. I helped her out with the computers, drew some blood for her (she said she wasn't very good at it) and found her brain when it went missing. She gave me a hug and a peppermint candy when I found her brain lol. It was very cute.

When I finally went on dinner around 2015, I decided that today would be the day I EKG myself. I've had a weird arrhythmia for a couple years now. Hard to type out, but it's something like lub-dub, lub-dub, lub-dub, lub......DUBlubdub, lub-dub. Everytime I have one of the weird beats, I imagine it looking like a PVC on an EKG. Not that I think/know that's what it is, but it's what it feels like if that makes any sense.

Alas, plain old normal sinus arrhythmia.

After all that effort to hook myself up (granted I only used 5 leads out of laziness) I hoped at least the mysterious rhythm would be identified. No such luck. Maybe I need to be hooked up for an hour or so, maybe overnight, to give my heart a chance to act up.

I even got the opportunity tonight to make the assignment for the unit at 1900 and 2300. I hope I did it okay, and no one was too mad. I think those assignments are easier than the 0700 one. At 0700, *everyone* leaves and you have to start fresh. At 1900 and 2300, only 2 people left each time, so you just sorta fill in the blanks. It was good experience, though, despite the battle with the copier that followed.

I can only hope for another good night tomorrow, day 5 out of 5 in a row. I can't wait for some days off!!!

Attention! Just a helpful PSA for all those involved in patient care:

2009-10-19T12:58:00.000-07:00

We use "emesis" basins as a spittoon for people brushing their teeth in bed. They make great trash receptacles for used tissue. If new and clean, they are useful for containing snackyfoods on the bedside table.

But when a patient turns into a vomit-breathing dragon s/he is *not* going to be able to aim for that little thing.

We try to make sure everyone has a big basin upon admission, but it seems there is never one in the room when the patient needs it OMGNOW!!!!! If you throw a basin away, pleeeease bring in a replacement one.

And that's it for my barf-related rant. :)

Thanks very much to NursingBirth for letting me use the image. Funniest thing I've seen online today. Guess that says a lot for my sense of humour lol.

Handwashing Detectors... interesting

2009-10-13T13:32:00.000-07:00

http://www.msnbc.msn.com/id/33297138/ns/health-health_care/

"When health care workers enter a patient's room, they wash up and run their hands beneath a nearby HyGreen sensor. The HyGreen sensor activates a green LED light on workers' badges to signal that their hands are clean.

A proximity monitor by the patient's bed then sends out infrared and acoustic signals to the badges, and when the health care workers approach, the monitor verifies that the green badge light is illuminated. If it isn't, the badges quietly vibrate to alert health care workers to clean up. "

"Whenever the HyGreen bed monitors verify if health care workers have washed their hands, they send that information, along with the time and location, to a wireless database maintained by the hospital's infection prevention team. That way, hospitals can know in real time which workers aren't washing up. And, if a hospital-acquired infection breaks out, they can pinpoint the source more accurately."

I'm all for handwashing. I know how important and essential it is. But this seems creepily Big Brother to me.

At least they're discreet. Though I'm wondering how clunky a vibrating badge would have to be. I'm picturing a restaurant pager hanging from my chest lol. And a vibration that buzzes as loud as my cell phone. That wouldn't be good. The last thing I need is a confused little old lady going "what's that?!"

I know I'm not perfect in my handwashing. Especially when I have my hands full of something as I'm entering the room. I wish we had some sort of clean surface to put things on outside the pts' rooms so we could use the gel, then grab the stuff and go in. Most of the time, I end up going in the room, putting the things down on the garbage can lid (because it's the only available flat space in the room), then using the gel. Not the most hygienic practice.

I look forward to the day when we can just irradiate our whole bodies every time we enter a room lol....

A quickie....

2009-10-13T12:36:00.000-07:00

I am in the middle of a scheduling block from hell. 5 on, 1 off, 1 on, 1 off, 5 on. Tomorrow will be my first day off. I don't know if I'm going to survive. This is frickin' ridiculous. I'm thinking I'll call in sick Thursday so I can get 3 days off in a row to recuperate. My back it sore as hell from moving heavy people around, and it feels like I'm walking on shards of glass.

As for the quickie, the other day I was going to pull up insulin. Our B station med room was out of the 50 unit syringes, so I went to A station. They had about 20. So I gave Material Services a call and they said they'd take care of it. I did my 1800 med pass, went to dinner and didn't think about it until 2100 fingersticks.

I checked the med room and we didn't have any more syringes than we started, so I called MS again. This time I was informed that they were out.

Yes, the storeroom of a *major* chain hospital was *out* of 50 unit insulin syringes. "We might get some tomorrow," I was told.

So tomorrow (ie, yesterday) comes and we still don't have them. We have to use the 100U ones, which are a pain in the ass to dose accurately. I asked the ass.man. about it and he said he'd call again. Here's hoping today we'll actually have the supplies we need to do our jobs...

But an even bigger hope is that Staffing calls me off today so I can rest my weary bone. I'm too damn young to feel this old.

Fun doctors' notes, part II....

2009-10-07T22:00:00.000-07:00

Do I sense a series beginning? Anyway, here goes:

"CODE STATUS: DNR/DNI and pressors okay partial code. Son Dr. R (psychologist ) easily reachable and involved in the patient's care. Go to sleep man"

I can only imagine what "go to sleep man" refers to... Is it a reference to the son being involved in pt's care? Or a note to another MD to get some rest? Or to himself?

No one knows....

Can't a girl catch a break?

2009-10-02T00:09:00.001-07:00

So it's 2253. Just did a final rounding check on my patients. They're all comfy in bed, falling asleep. Came back to the computer to make sure I'd finished all my charting. I notice on the monitor that one of my patients' pacemaker is acting very strangely. He'd been tachy in the 120s all day (each QRS with a pacing spike before it) but this time each QRS had two pacing spikes. Having never seen that before, I decided to call cross-cover and let them know. He'd had the battery replaced recently, and I figured any info on it would be helpful.

Two minutes later I get a text from the monitor techs. "rm 55 leads off. thx"

Immediately I get a sinking feeling. Rm 55 is a 90/f who fell yesterday and broke her hip. She has Alzheimer;s, and is confused easily. When asked, she is oriented to person and place. In an odd way, though, it's like her answers are recited and not understood.

"Do you know where you are right now?"

"Big Shiny New Hospital"

But she does not know what it means to be at the Big Shiny New Hospital and she can't remember why she's here.

So I head on down the hallway with the sneaking suspicion that she pulled all her wires.

Why can't I ever be wrong?

Not only has she pulled her tele, she is naked except for her SCDs and a smile, and her two IVs are sitting on the bedside table, along with some kleenex that was obviously used to stop the resultant bleeding.

At that moment I get a call back from cross-cover, who tells me to do an EKG on Mr CrazyPacer. Standing outside a naked woman's room.

I get off the phone as quickly as humanly possible and attend to Ms Sundowner. Still A&Ox2, and pleasant as can be. As she had all day, she would respond to any statement with "Whassat?" until it was repeated several times. I tried to explain, yet again, that I was her nurse and that I would help her. Happened to see my watch. 2257. There's no way I can clear this up in 3 minutes, so I call my Resource.

She comes in and takes over so I can give report to the poor girl who is taking over for me.

Report is given in record time, with much sighing and eye-rolling (understandably. I love you S! *grin*) from my replacement. Since we've finished quickly enough, I tell her I'll take care of Mr CrazyPacer's EKG.

It's 2315 and I get into the room and start up the machine, and I get a call from the Ass.Man. who is demanding to know why Ms Sundowner is getting a sitter and wondering what medications I could have given her instead and asking why I am not rounding more frequently on a patient that I know will be sundowning because she has a history of dementia and what isn't she getting something around the clock for her dementia and I nearly yelled at him to STFU.

I told him that I went by her room about twice an hour and she was sleeping the whole shift. She had no PRN anti-crazy meds and nothing around the clock. The only thing she was taking for Alzheimer's was Aricept. He then starts badgering me about what the MD said when I called (but I hadn't gotten a chance to call) so then I got questioned on why I didn't call. I told him that I knew nothing of the sitter because I asked the Resource to take over so I could give report, and that anything that happened between then and now was something she initiated. I told him I was trying to do an EKG and got off the phone as quickly as possible.

I apologized to Mr CrazyPacer (who was awesome btw) and did the EKG as best I could. The machine decided to hate me and I forgot which button printed out the kind of strip the MD wanted. Eventually got it and then got the hell outta Dodge.

The last thing I wanted was to run into the Ass.Man. on my way out.

I did the best I could, and all I got was him taking out frustrations on me at end of shift. AAARRRGHHH!

I made it through my first year!

2009-09-22T23:59:00.000-07:00

I want to take a moment to recognize all the other Not-So-New Grads who survived the first year with me. You guys are all amazing and wonderful, and I can't think of a better group of girls to go through hell with. Without the support and humor you guys provided, I probably would've done something insane by now. You rock!!!

It's hard to believe a whole year has gone by. I'm sad that some people didn't make it this far, but I wish them all the best in their futures. :)

I've been debating on getting a nursing-related tattoo to celebrate a year, though some tell me I should wait until five years. When I'm *really* sure.

Any thoughts out there in internet-land?

Sometimes the doctors' notes amuse me...

2009-09-19T11:38:00.000-07:00

At our hospital, when the main MD "signs out" for the night and cross-cover takes over, the MD will write a little note with plan of care for reference. I found this little gem the other night:

"If pt decompenstes with generalized respiratory badness, call pulm. Okay to titrate up 02 if necessary. If pt spikes temp overnight, do not re-culture. Don't even *think* about it.... ;) "

Yes, including the winking smiley face. And "respiratory badness" is apparently a technical term now, so that's cool. Now my friends won't give me crap when I describe things as "________ badness" because we know it's officially sanctioned.

Just a little silliness to brighten up the day :)

It's raining crazy at work

2009-09-18T23:59:00.000-07:00

So usually our unit just gets little old people with CHF, COPD, GI bleeds. Stuff like that. Rarely do we get anyone under 50.

Tonight we got two, both with psych issues. They came to our unit within 5 minutes of each other (around 2030). One was an admit from ED/PACU, the other a transfer from stepdown.

First one was a mid-40s male who came to ED with "penile pain." I'm thinking, there's got to be something more to this. Penises don't just hurt without a really good story. So here it is:

"Patient placed 5-6 kidney beans in his urethra last night for sexual pleasure. He has been unable to void since 10 PM last night."

Kidney beans? Seriously? I have to wonder at what point it seems like a good idea to place small, irretrievable objects into ones urethra. Didn't he know they make toys for that? Hell, if you want the lumpy feeling, at least use beads on a string or something! Someone should make a PSA (a la Scrubs) about not sticking things where they don't belong.

So the poor guy had to be put under general anaesthesia for a cystoscopic removal of the kidney beans. He must've had some sort of complication, because post-op he ended up with us. Either that or they were out of med/surg beds. *shrug*

Unfortunately, I was just Resource, not his primary nurse. So I didn't get to hear it straight from the horse's mouth. I'm sure it was an interesting story...

Our other crazy patient was in her late 40s. Attempted suicide 4x in the last 3 months or something like that, because she felt like a failure as a wife and mother. (Aside: killing yourself is the *ultimate* in failing as a wife and mother.)

Anyway, she had expressed suicidal ideation, so her husband took her to the ED. While in there, she went to the bathroom. When she came out (after an unknown amount of time) she told one of the nurses that she had taken "about 60 pills" which she had smuggled into the ED in her vagina.

I checked *all* the subsequent notes in the computer. *None* of them mentioned whether the pills were in a bottle, or just shoved up in there. For the sake of "ewwwww" I hope to god they were in a bottle.

Anyway, the woman was a terrible historian, and couldn't remember if they were Cymbalta or Klonopin or what. All the notes had different meds listed. But by my accounting, if you take 60 of *anything* you'll probably get sick.

So they dropped an NG and did gastric lavage, bringing up "no pills or pill fragments." I find that odd, cuz pills take awhile to dissolve fully. So either she took the pills earlier than she said she did, or she didn't take any at all. But she became fairly non-responsive and lethargic, so they brought her up to stepdown for monitoring. When she got a little better, she came to us. She had at 1:1 sitter that came with her, so that was nice.

Both of them are to be evaluated by psych when they're a little more "with it." I wish I could be a fly on the wall for those conversations....

UPDATE: I asked one of the RNs who took care of kidney bean guy, and she said that the reason for the beans is that if they stay in long enough, the body's natural moisture makes them swell, which apparently feels good. So there you have it. :)

Dear pt in rm 60,

2009-09-07T14:26:00.001-07:00

Please stop trying to sabotage your own health. It kills me to see you every day, getting better, but not getting better as quickly as you could be. I know it sucks being in the hospital, but combating everything we do is just hurting yourself. Please meet us halfway at least. It's the least you can do for yourself.

Love, PurpleRN

She came in because the swelling in her legs had gotten so bad, she could barely move them under her own power. The unit she was on tried IV lasix a couple times a day but it kept dropping her BP. So they sent her to us for a Lasix drip.

The swelling in her legs caused her considerable pain, so she had Dilaudid on board. She was a clock-watcher. The moment enough time had passed, she'd ring for another hit. And get rather upset if it took more than 10 minutes to get her meds. I understand that being in pain sucks, but we have people circling the drain on our unit. Your legs are slightly less of a concern sometimes.

She's on fluid restrictions because of the edema. Fluid restrictions suck. Imagine some "high faluting" doctor saying, you can only drink 1.5 liters (~6 cups) of fluid today. Period. Well what if you don't budget properly and drink 5 cups of water in the first 12 hours of the day? Screwed, my friend. So she'd been sneaking drinks and not reporting them to the nurses. Her husband/partner-in-crime wasn't helping on that front either, showing up with fast-food meals.

She would go on "walks" with her husband (he pushed her in a wheelchair) a couple times a day, to the atrium near L&D down the hall. We explained that she was going out of telemetry range, and we couldn't monitor her heart out there. She didn't care. And she would come back smelling of cigarettes. Our campus has a strict non-smoking policy, and we told her we could get her the patch while she was in the hospital. She refused, saying it wouldn't work. I hate people who automatically say no without trying.

She threatened to leave AMA if she couldn't smoke, so the doctors let her go off campus with a security guard for cigarette breaks a couple times a day.

What the hell? "THRIVE" my ass! Just because a patient gets whiny doesn't mean you bend over backwards to thwart her recovery!

I bet you're asking, well why not just let her leave AMA? Because she said, "I'll just come back to the ER when I'm done with my smoke," and that creates more work for us. (Aside: I'm of the opinion that if you leave the hospital AMA, you are not allowed to seek medical help for at least 48 hours. If you die from your own stupidity, so be it)

Doesn't advocating for your patients include trying to protect them from themselves? Sure, she's doing better than she would be if she wasn't in the hospital, but she's not getting better as quickly as she could.

Last but not least, we've been very concerned about falls on our unit lately. Our patient population is such that they're mostly too unhealthy to get up unaided, but not with-it enough to realize they need help. Or too proud to ask for help. We even had a recent meeting on how to reduce falls. The only time I took care of this patient was when she came to us from the other unit. I told her that if she needed to get up, she needed to call me first. Obviously, since her legs were so swollen (and she is obese) she couldn't move very well.

My shtick is to say, "I know you don't want to bother me by calling for help, but I'd much rather help you to the bathroom safely than scrape you off the floor when you fall. Plus the paperwork is *insane*. Please don't make me fill out paperwork" Usually it gets a laugh and a promise to call before getting up.

Well she's been with us a few weeks now, and apparently thought she was in good enough shape to get up on her own. She ended up on the floor, requiring xrays and various other tests for broken things.

I know you don't want to be in the hospital anymore. I know you think 3/4 of our nurses are idiots. But you're not doing yourself or anyone else any favours by screwing up your recovery with what *you* think is right. Your treatment team (MDs, RNs, MSWs, PTs, etc) went through lots of schooling and training and hell to know what to do to get you better and get you on your way as fast as possible. Believe it or not, we know what we're doing.

It makes me wonder how we can properly advocate for patients that won't accept it. How can we encourage people to take ownership of their health? Noncompliance increases complications and drives up medical expenses, neither of which are in *anyone's* best interests.

Any ideas?

Update to "Siiiigh"

2009-09-07T14:19:00.000-07:00

So after all that silliness about being requested to stay 16 hours, I ended up going home early :)

At about 1730, I get asked if I'd like to leave early, as we will be overstaffed starting at 1900 when the 12s come on shift. Of course I jump at the chance.

At 1900 when I'm giving shift report, one of the 12s comes up and says "If you want to stay, I'll go home and come back at 2300" as if he's trying to do me a favour.

I became briefly worried, "Wait, are you asking me to stay or telling me I *have* to stay?"

"Do you want to stay? Cuz I'll go home. You can stay if you want."

"Um, no thanks. I'm happy going home..."

Afterward, I was told by the nurse I was giving report to that this guy works 2 jobs, and that's why he always looks exhausted, so he probably wanted another 3 hours of sleep. I feel kinda bad about it, but I'm also greedy for time off.

Sorry dude.

Siiiigh

2009-09-04T13:55:00.000-07:00

So I called Staffing this morning to ask to be considered for the day off if we are overstaffed like yesterday (one of the girls was put on committee and then sent home early). It's rare that they call back, but it's like the best present in the world when they do.

So when my phone lit up with !!WORK!! my heart got very jumpy and excited. A free day off? Yay!

Turns out it was not Staffing, but the BossLady asking if I wanted to plan ahead to work 16 hours tonight.

Ha. Right.

I politely declined.

Guess I'm definitely not getting the day off.

What is it with little old men?

2009-09-03T23:38:00.000-07:00

Two have tried to kiss me in the last two days. Sure it's a little cute and funny, but how do you respond to an octogenarian's inappropriate advances?

The first one was in for breathing problems. He was always up and about, with his heart rate skyrocketing and his O2 sat plummeting. I couldn't convince him to call me before getting up, so I put a lot of extension tubing together so he could get to the bathroom without taking the oxygen off.

Anyhoo, I'd finally gotten him settled in the chair and he was griping about how he couldn't figure out the TV, and really wanted to watch the baseball game. So I flipped through the channels, and found the appropriate game. He said "Yippee" like the cute grandfather in Charlie and the Chocolate Factory and "You deserve a kiss for that! Just one on the cheek"

I politely declined.

The next one in question had just arrived from ED earlier that shift: an unnecessary admission for high blood sugars. Paranoid wife. At any rate, I was finishing up my end-of-shift things and stopped in the room for a last check before report.

I asked, "Do you need anything, or is there anything I can do for you before I go off shift in 15 minutes?"

"Well, I *usually* get a kiss goodnight before bed..."

I paused and said, "I'm pretty sure your wife won't be happy about you kissing a young nurse at the hospital."

"I won't tell if you won't!"

My main question is, "Does it ever actually work?" C'mon guys... give it a rest already.

I worked my first (and last) double on Tuesday

2009-09-02T13:01:00.000-07:00

Oh what an interesting experience.

I'd been having a really good day on Tuesday. I was Resource (along with L, another not-so-new grad). It was pretty busy, and I had to jump in feet first to get a patient discharged. His family said that if he was not ready to go by 1600 they were not going to be able to get him and he'd have to stay another day.

After that had all gotten settled, it was a pretty smooth shift. Gave people their breaks, helped with fingersticks, did other Resource-y stuff. Nothing eventful enough that I remember it.

But near the end of shift we get word that 2 or 3 of our night shift nurses have called in sick, and they need people to stay double.

Now, I have to say that it's a running gag at this point to ask me to work a double. The Ass.Man. (teehee. thanks to J for the abbreviation) still asks anyway, with a huge grin on his face, knowing I'm going to say no. I'll be the *first* to volunteer to go home early, but I'll be damned if I work anymore than my contract says I have to.

But today I'm thinking, "Well, things are going pretty well. We have 24/26 beds filled, and 6 RNs (we have a 1:4 ratio) so we're full. I guess I'll stick around just to see what it's like."

So I shock the whole world by agreeing to stay double.

I give the boyfriend a call and let him know I won't be coming home as previously discussed, and that if he really loved me he would bring me Starbucks and a salad from Jack-in-the-Box. Not only did he come through for me, he drove miles to find a Starbucks open at midnight, and he got food for L as well. He's so sweet lol.

The first part of my second shift was cake. Potter came a little after midnight, and I took a 15 to show him around the unit and hang out a bit. We ended the tour when one of the pts became confused and his nurse was too busy to re-orient him.

He was a sweet guy who "just felt disorganized" and couldn't figure out where he was. I reminded him he was in the hospital for a bowel obstruction, and that the NG tube was to keep his stomach from filling up with gunk (technical term). He said he knew all that but just couldn't figure out where he was. So I got him up out of bed and walked him to the doorway. Pointed out the main station down one way and the big window down the other. Eventually he got it and was content to try to sleep.

After that, I asked the 3 nurses on my side (there are 2 stations on the unit) when they wanted to take their dinner breaks, offered to help out with anything they needed, and mostly just sat on my butt, slightly bored.

Heck, one of my nurses didn't even tell me when he was going on dinner, or give me his phone or anything. Very different from on PM shift.

Then we found out that ED was OMGFULL and that one of the resources (me, apparently) was going to take an admission. Ok, not a huge problem.

So at about 0330 I decide to take my dinner (mmm southwest chicken salad without the chicken) and relax before I got report. I also have an insane urge to brush my teeth, because this is about the time I go to bed normally. Thank god I keep a toothbrush in my backpack :)

At 0355 L pops her head in and says, "Did you get report yet on 54?" "No, why?"

"Because he's here"

WTF?! Seriously ED. That is *NOT* cool. You do not bring a patient up to the floor without giving report or warning. I understand it sucks being full, but blindsiding a nurse is just not fair.

And this is where the clusterfuck began.

If we had gotten report we would've known that the pt was on droplet precautions (ie, he was coughing and may have something communicable) and we would not have assigned him to one of our 4 double rooms (the rest are singles).

So at 0415 we have to start playing the bed-shuffle game. One patient got transferred to another unit, and then about 5 different patients had to get switched around to accommodate the nursing assignments, because it would suck to have a patient moved all the way across the unit halfway through your shift.

Finally get everyone settled and I try to do my admission the best I can with the few remaining hours of shift. Also trying to be helpful to the other nurses, as I only have 1 pt to their 4.

As the sun came up through the windows I started feeling really exhausted. And when the day shift nurses started streaming in I got the most surreal feeling. It was like I was on the wrong end of time. It was funny watching all the Day RNs' faces register the fact that I was there at start of shift, not end. Barely concealed surprise and shock, and quite a few laughs and "What are you *doing* here?"s

I give report to whoever was taking my patient, then try to give report to the Resource whose side I was on earlier that night.

Got out of there about 0745 and headed out. Immediately, I was confronted with something I hadn't expected to deal with: traffic.

"Oh god. I don't think I can deal with this" I felt the strangest kind of awful driving home, realizing that I had about 6 hours to get home, sleep, and get ready and leave for my normal shift at 1500.

I honestly don't remember much about my regular shift. I responded to frequent statements like "You honestly stayed double? You never stay over! What made you change your mind?" I know that my Resource saved my exhausted ass on a couple occasions. I made promises to patients that I forgot to keep. One of my patients was a retired L&D nurse, and she was very understanding about my situation. Didn't make me feel any better about it, though.

Near the end of my shift I realized that I was getting paid time-and-a-half (or double?) to be a *terrible* nurse. And as much as I'm sure my paycheck will be nice this time around, I can't do that to myself or my patients again. It's not fair to anyone.

At around that point, the Ass.Man (who is becoming cooler these days) comes around and asks people for their Starbucks orders, as he is going on a run and apparently won the lottery. I put in a request for a nonfat vanilla latte (mmm) and go about finishing up my to-do's. I felt a little bad, as I think J may have been trying to just get stuff for the people who were staying double but no questions were asked and, hell, I feel like I deserve free coffee on occasion. And man was it good. Who cares that I was drinking that much caffeine so close to midnight lol.

So I guess if I were to evaluate everything, the only situation I'd work another double is if we were *full* (26/26 beds taken) *and* I was Resource *and* I wasn't working the next day. Because I have better things to do with my life than work myself to death.

In April I wrote a post called "Nursing is a 24 hour job"

2009-08-22T20:45:00.000-07:00

This, I suppose, is somewhat of a corollary.

Two days in a row, I have gotten patients from the same nurse. Rumor has it that she used to work ICU/Stepdown. You'd think she'd be able to handle some measly Tele patients.

Two days in a row, I started receiving report 10-15 min late, because she is running around crazy trying to finish things. I *know* day shift has a lot more going on. But when you give report late, you steal 15 minutes from my shift. I have my day carefully calibrated, and even 15 minutes can screw things up sometimes.

Now that we are computerized, the first thing I do when I get on is set up my eBrain. I still have a paper brain, but this one keeps my patients where I can see them quickly on the computer. Yesterday, I set things up to find that one of my patients has 6 overdue meds that were scheduled for 1330 & 1400. The nurse is aware of one of them, some IVIg (an immune factor), is late because the pharmacy needed to send up special tubing. That's fair. But what about the other 5? I know that I have a 2200 med pass (one hour before end of shift) and I plan accordingly, trying to get them all in starting at 2130. But she didn't even realize they were there. Today, there were 2 overdue meds each for 3 patients.

This blows my mind, because she should have an "Overdue Med" column on her eBrain. I see mine every time I use the computer, multiple times an hour.

Usually her excuse for not being up-to-date with everything is that she got an admission. I know the day shift is more used to discharges than admissions, but come on. It's not like you have to wait for the UA to take all your orders off and put them in the chart. Or you have to wait for the pharmacy to receive all your med orders and get them into the computer. It's all done instantly. Click click click click click. Acknowledging new orders takes seconds. The admission interview, granted, is a little longer than before, but it's still mostly the same. And charting is another set of clicks.

I wonder if she forgets she has Resources. Or if Resource is too busy on Days. I know that the moment I found out about all the overdue meds, I let my Resource know that I'd need help catching up with my day or I'd be way behind. And my Resource went over and passed the meds so I could assess my patients and start my shift properly.

Apparently I'm not the only one complaining, because the manager asked me to write up specific instances for an employee performance review. And she got a talking-to. I feel really bad about that, because I know what it's like to get a talk from them. But I also hate having to clean up after people who should know better.

A compliment last night

2009-08-11T11:40:00.000-07:00

I had a pretty easy load after one of my patients was DC'd @ 1600, leaving me with only three. So when one of my pts complained about her gown being wet (not sure if it was incontinence, a spill, or her gown got dunked in the bedside commode) I figured I should take care of it. Nothing better to do, so why bother a CNA?

I got her gown changed, and decided she should go for a walk. So we took a slow 1/4 lap around the unit. When we got back, I noticed her bed was also a little wet, so I set her up in a chair and got fresh linens.

A little after my return, one of the CNAs (a tiny little lady who used to be a schoolteacher) was in the room doing her 2000 vitals. I start remaking the bed and she remarks, "You're doing *my* job"

I reply, "Well, *you're* also doing your job right now. It needs to get done so I'm doing it."

"You sure you don't want any help? I can take care of it when I'm done with vitals."

"No, I got it. Don't worry"

She looked a little shocked.

Then she pushed the vitals machine to the side, smiled, and stood on tiptoe and stretched her arms up to give me a hug.

"You're a good nurse. Thank you."

:)

I originally started writing this one at the beginning of July. Apparently I suck at follow-through...

2009-08-09T00:30:00.000-07:00

We switched over to computerized everything on Saturday June 20.

It's been 2 weeks. In that time, I've worked 8 shifts, which is just about enough time to become comfortable analyzing the system.

The first few days were insane. Everyone was freaked out. Our shift especially, since we were the first to do *everything* paperless. The tail end of the day shift caught the beginning of the "cut-over" so they had done a couple things, but they were mostly on paper. Since we didn't have access to the paper charts, a *lot* of things were missing. It was hard to find the previous assessment info. The UA was confused about where things were supposed to go, and kept forgetting that there was no paper.

Thank god they only gave us 3 patients instead of 4, so we could spend some extra time getting acquainted with the system. We had roving experts to help us figure out where certain things were located when we were panicking.

I managed fairly well.

The 2nd day I got my first admission. It came at a very inopportune time, right around 1800 med pass. Not only that, but dialysis wanted her to come down right away. I barely got the admission work done and sent her over. She came back 10 min before end of shift, with all her meds flagged as "overdue" on the computer. I didn't want them to get forgotten by night shift, so I didn't resolve them. Because when you resolve them they go *poof* I still don't quite know how to reconcile the situation.

Since then it's been fairly smooth sailing. I'm still a little sketchy on sending people to procedure. I had the honour of figuring that one out during the first 30 minutes of my shift yesterday when one pt had to go to the cath lab. Apparently there's a procedure protocol or something. I hope I did it right. I haven't heard anything back, so I'm guessing it's all good.

And now, for your enjoyment: A list of good stuff and bad stuff!

The Good Stuff

Time Saving! My shift assessment goes like lightning, just clicking through the applicable items. And I can finally click "No change from previous" for my 2nd assessment of the day without looking lazy like I did on paper.
New Orders in Real Time! I can call a doctor and ask for an order, and it will be put in the computer within minutes. No scanning/faxing things. It's just there. *poof* like magic
No More Annoyed Calls to Pharmacy! If there's a problem with a medication, I can click on the med's profile and sent them a note about it. Like "He got this medication in ED. Please change administration time to reflect" or "Med not in either Pyxis or cassette. Please send." Missing medications are figured out much more quickly
Orders don't get "thinned" out like they did on paper. If it's still active, it's still there to see. So if you're wondering "Is there really an order for this?" you can look through for it.

The Bad Stuff

The Amazing Capacity for Mis-Charting! You should *not* be able to put the charting for a chest tube's output in the same flowsheet as the results for fingersticks. But with this system, you can add a "Line/Drain/Airway" anywhere you damn well please. I think a lot of people go "Oh right! He has a ______" and then add the thing, no matter where they are charting at the moment. And people, for the love of god, if it's a piggyback medication, add the Piggyback/Bolus group! Not Maintenance fluids! Same goes for actual boluses of fluid. Makes me crazy when it looks like maintenance fluids have been charted, but the MAR says it was a one-time fluid bolus. AAARRRGH!
Dealing with Labs! Say a bunch of labs have been ordered over the course of the last day or two or three. They all show up in the "Lab Orders" section of the report. Even if they've been drawn and sent days ago, they still show up. So it makes you wonder if it's been done, so you have to hunt thru the lab results to see if there's evidence of its existence, or call the lab to see if they've received the sample but the lab's not done with it yet. There needs to be a "complete" button next to the lab orders. I've been adding notes at the top saying things lik "MRSA swab sent 7/3 @ 1900" just so the next people have an idea what I've done and haven't done.
Dealing with Lab! If the doctor puts in the wrong kind of order, it looks like we are supposed to draw routine scheduled labs when it's actually more suited for the Lab to do. And I haven't figured out a way to switch things from unit-drawn to Lab-drawn. And man do the Lab people get annoyed when you come up to them with a label asking "Can you pleeeeease draw this for me?" Sometimes the stickers print up on the unit, sometimes down at the lab. I still haven't figured out how the Lab clipboard works in terms of getting things drawn in a timely manner. Bad blood is brewing, I think.
Having to constantly leave the area you're working in to find other things! Doing an admission is a pain in the ass. You go through this "Admission Navigator" which makes you switch out to other parts ("Go to Orders," "Go to Patient Plan," Go to MAR") of the program, then come back to where you were. Can't they just make it show up all in one spot?

But really, it's all been pretty positive. As I go along, I'm sure I'll get even better at it and it'll feel like I never used paper charts to begin with. Fingers crossed... :)

Not quite sure how to title this one....

2009-08-09T00:19:00.000-07:00

Tonight I was at a party at a friend's house. One of the guests was transgender, MTF. She told me that she'd graduated with a degree in kinesiology/sports medicine about 10 years ago, but never did anything with it.

She told me she'd just been accepted to the BSN program at the local university. I congratulated her and wished her the best of luck.

I hope to god she is tough as nails.

Nursing school is hard enough even when you look/act like everyone expects you to. The patients and their families *do* judge you. You can be the most kind, knowledgeable, and professional RN on the planet, but some people will see your nose ring and decide you probably don't know what you're talking about.

I know a couple guys in my nursing school who could not complete assignments during their L&D rotation because the new moms wouldn't allow them to meet up for a follow-up visit. A lot of people still don't trust the motives of male nurses. They assume they're gay, or weren't *quite* smart enough to be MDs.

I don't even want to think of the hell she might go through, just to get her degree. Let alone get a job.

If she survives it all then I think she wins for most tough RN ever. Here's hoping...

Weird ass dream about a patient....

2009-07-24T13:09:00.000-07:00

There was a patient on our floor recently for a GI bleed. The docs were giving him Colyte to clear him out for colonoscopy, and every time he had a BM it looked like a murder scene. Soaked through the bedding, dripped on the floor. Really bad.

Yesterday someone finally said "You can give him all the Colyte in the world, it's an active bleed and he's not getting any better" and he was moved to a higher level of care unit.

Because the guy is in his late 80s, the docs are very wary of doing surgery. And this is where my dream begins...

I'm talking with another nurse about the crappy situation this guy is in. "Either they do surgery and he likely dies from anaesthesia, or has to have an ostomy for the rest of his life, or something like that. Or, they do nothing and he bleeds to death. Every bag of blood we put in comes right back out"

I start asking around if anyone knows what eventually happened to this guy, and came across a whiteboard with patient names on it (not unlike the one in our station, but a little different). Next to this patient's name it said "Dead."

I got very freaked out. Oh man, I just took care of this guy, and he's gone already? Craziness! So I go walking around some more and come across the patient's family members.

I ask them what happened, and they start talking about how this has been a difficult time for them, but no, he's not actually dead.

What happened in reality was that after all the bleeding from between his legs, he decided he was supposed to be a woman, and that he was just on his period. And had a sex change operation. The old "him" was dead, but "she" was alive and well.

And thus ends my dream. I wish to god I knew what to make of it.....

I think there's something wrong with my brain.

It's official. My manager hates me.

2009-07-16T12:29:00.000-07:00

She came up to me yesterday and said "Purple, I've volunteered you for a new project. It's about keeping the care boards updated."

Care boards are in each patient's room. They have the date, room number, room phone, MD's name, RN's name and phone number, and the "plan of care" for the patient's stay.

It is to be fully filled out and updated daily.

And she wants me to be in charge of making sure it's done for "maybe 5-8 rooms" every shift I work.

Note that. When I am *working* on the floor with with *patients of my own*, she wants me to go around and check other people's rooms to make sure their boards are filled out.

We *have* people that do this, when they're on committee and don't have anything better to do. I have better things to do, dammit.

And what's this BS about volunteering me? That's not how volunteering works, *especially* when it's something that could adversely affect my patient care.

I don't know what she's trying to pull here, but I don't like it...

One last important thing....

2009-07-07T03:28:00.000-07:00

Today I received in my work email a very urgent notice from the head of all computery-stuffs.

Apparently we are *not* to be using hospital computers to stream Michael Jackson's memorial service from the interwebs tomorrow, as it ties up bandwidth required for critical patient care applications.

They *really* deemed it necessary to send out an email? Even if I *did* give a crap about the memorial, I don't have time to sit and watch *anything* during my shift.

Brilliant.

And sometimes it ends up okay...

2009-07-07T01:18:00.000-07:00

At 1900 they switched me to committee, where I had time to write that last entry. I also ate dinner, helped reposition a patient, delivered some lab labels to a new admit, helped reinsert the NG tube, called pharmacy about a missing medication, did a fingerstick, started an IV (one shot! gorgeous forearm vein. probably coulda gotten a 16 in it), and showed some people how to find a certain report on the computer system.

Felt way more useful than when I had patients.

And then, afterward, I went to Denny's with four of the best friends a person could hope to work with. Nothing soothes frazzled nerves like a strawberry milkshake and some bad-for-you food, mixed with an enthusiastic gripe-fest.

Thank god for my coworkers. Sometimes they're the only thing separating me from a 5150 hold :)

Assignment Despite Objection

2009-07-06T20:49:00.000-07:00

A Day Shift RN filled out a form that documented her objection to her pt load, because it was unsafe. She encouraged me to do the same.

My load was way too heavy. I cried for the first time in a month or two. Sigh.

One pt was here on suicide watch. No reason for her to be here. Heart is just fine, needs to be in a psych facility. She has a sitter for 1:1 observation. Waste of a sitter. Very tearful, but not very demanding. Not really a problem.

One pt was here for an possible infection in a dialysis port. He's mostly healthy and wants to go home. But he's on a heparin drip, which is a high-alert medication that also requires monitoring thru frequent labs. And he's been bleeding. One of his IVs yesterday, and his dialysis catheter today. And one of his IVs was starting to annoy him, and it had to be DC'd and replaced.

One pt came from ICU th'other day. Part of her intestine ruptured, so she had surgery to clean it out and make a colostomy. She has a colostomy bag, a line of staples (which were removed too early by a med student) and a few drains. She was in ICU for respiratory arrest, and is on high-flo O2. She hasn't been eating, so she's on CPN, food thru the veins. This means fingersticks q6hrs. She also doesn't swallow well, requiring meds to be crushed in applesauce. Her family is concerned about her recent mental fuzziness. She has a PICC line. All labs are RN drawn

One pt was also in ICU in the past for respiratory arrest. He had a PEG tube placed, which he pulled out a few days back. This means there is a hole in his stomach and abdomen. To prevent infection, there is an NG tube to suction to make sure nothing stays in his stomach. He has been pulling his tube out at least once a day every day. He's been on restraints, but his day shift nurse decided he was doing okay enough to have them off. Not the brightest of ideas. He also has CPN, requiring fingersticks. He has a PICC line, and I got orders at the beginning of shift to hang 5 extra bags of medication, which I have to juggle with his ABx and anti-seizure meds. He was doing ok until 1900, when (surprise surprise) he pulled his NG tube. The Dr has now said that *no one* is to take off his restraints for at least 3 days, because repeatedly jamming a tube down his nose is rather bad for the tissue. He's also on contact precautions.

I know on paper it doesn't seem so bad. But it's too much for a person to handle. I only survived because my resource did a bunch of meds and lab draws for me, and because one of the RNs who wasn't even supposed to be doing pt care did meds for me.

I barely had time to assess my patients before having to work on the meds.

I tried not to get overwhelmed but I couldn't stop it.

Hooray for crying in the breakroom. And bathroom. And almost on the floor.

I am so glad I have the next 2 days off. If not I'd probably call in sick.

Fun with the Scale

2009-06-29T23:46:00.001-07:00

While walking down the hall at work today, I decided to pop on the unit's scale, just for a kick.

I weigh a good 5-6lbs more at work than I do at home.

Why is this?

Pocket-stuff, my friends.

In my everyday life, I carry many things in my pockets. The front left pocket gets my wallet and a pen. The front right pocket gets my chapstick, pocketknife, and cell phone. The right belt loop gets my keys.

At work, I have much more required stuff, and so many pockets to put it in! I continue to carry the standard stuff, sans keys.

The front left scrub-top pocket gets a sharpie, a highlighter, a dry erase marker, 2x2s (gauze), and adhesive-removing wipes (best thing ever invented for removing tape from hairy people).

The front right scrub-top pocket gets my work phone (which I have the habit of occasionally taking home with me), my alcohol wipes, and my brain. Also, near the end of shift, my flushes for IVs.

The back left pants pocket gets my "Non Interruption Wear" sash, which is "road-crew reflective" yellow, and rarely gets worn because I am so busy I forget to take it out of the pocket. I also find that it does not work. Nurses/Doctors are so focused on whatever question they have to ask you that they don't notice what you're wearing, and patients/family members stop to ask "What's that about?".

The right knee pants pocket gets my stethoscope and my scissors (it even has a scissors-shaped mini pocket!).

Yup. That seems like about 5lbs of stuff to me. No wonder my knees are starting to give out already.

I assure you I'm fully qualified.....

2009-06-20T01:34:00.001-07:00

As many of you know, my goal in life has never been to be a Telemetry nurse.

No, my friends. My true love is Labour & Delivery. My ultimate desire is to be a midwife. Someday it will happen. Siiiigh.

The topic came up today, when a friend pointed out a very pregnant music teacher at a jazz concert and said "Haha. Don't you wish you had to deal with that?" I think I surprised him when I said "Kinda yeah..."

I told him there were many reasons, but one of them sticks out.

When I was in Nursing School during my rotation and preceptorship in L&D, each labouring woman would ask the same thing. "So do you have children?"

And when I said no, they'd each get this fleeting look that said "How do you expect to take care of me if you've never been through this?"

Granted it was only split-second, and no one ever *said* anything, but I could tell it was there.

I don't have to have gone through it to be a positive, supportive, sympathetic, attentive nurse. It's part of the job, no matter my life experience.

And it's only in L&D that you get the question.

My CHFers never ask, "So, have you ever had fluid build up in your lungs because your heart pumps inefficiently?"

My GI bleeds never ask, "So, have you ever had blood gush out your anus in terrifying amounts?"

My Diabetics never ask, "So, have any of your toes died and turned black because you weren't careful with your diet and medication?"

How many surgeons get asked if they've had a total knee replacement? How many dermatologists get asked if they've had skin cancer? How many physical therapists get asked if they've had to relearn to walk up stairs?"

It's irrelevant if it's a yes or a no. Fully trained and fully qualified is just that. You don't have to have suffered from it in order to take care of it.

Still, I look forward to the day where a labouring woman can look at me and ask "So, do you have children" and I can say "yes" and see a look of relief instead of concern, and they believe that I am actually fully qualified.

I got complimented by a doctor!

2009-06-16T00:38:00.000-07:00

Also, had another really good day :) I like that they're getting more frequent.

So it's the very beginning of shift. I had just finished report (which was thorough yet concise and only took 15 mins instead of 30. yay!) and was sitting down to get my ducks in a row for the shift.

The Dr came over to my "office" and asked about a pt's diabetes teaching. Apparently he'd been refusing insulin teaching, or people said it'd been done when it hadn't. Regardless, he needed to learn the difference between Regular and NPH insulin, and how to draw it up, and how to inject. His wife was learning as well.

The Dr was telling me about this and what things needed to be done for the pt to go home tomorrow, and then said:

"I'm really glad you are his nurse. You always get things done."

YAAAAAAY! Someone notices and appreciates the things I do! Happy Dance!

So I got cracking on the teaching, spent at least a half hour in the room making the pt and his wife both practice drawing up and injecting insulin. I have some worries, but I think they'll do okay.

Beyond that, I only had 3 patients until 1900. Diabetic guy, girl my age who is steadily falling apart worse than my sister, and quiet old guy with urosepsis.

No one had any emergencies. There were no missing medications. No accidents to clean up. Beautiful.

And then at 1900 I picked up one of the 12hr nurses' patients, a younger (for our unit) guy with cancer. All he wanted was some quiet and sleep. I'm *always* happy to provide that.

I finished all my med passes early, did all my charting early, and even got to take all my breaks.

I love the days where it finally feels like I'm getting the hang of being a nurse.

Here's hoping tomorrow is just as smooth.

[knocks wood]

Results of the meeting I mentioned a few posts back...

2009-06-05T15:13:00.000-07:00

So apparently Manager T got an email a little before I went on vacation, complaining about some of my behaviours and my negative attitude. She decided we needed to have a "heart to heart" in order to clear things up. We had a Union Rep present as a witness, but she didn't technically have to be there as the meeting wasn't related to disciplinary action.

The first thing T mentioned was about the phone. Going back a couple weeks, one of the higher ups (resource? charge? I forget) said "You should put the cover back on the phone. Those things are really expensive, like $1000 if they break."

I hate the covers. Everyone hates the covers. They are bulky, the material feels weird, and you can't quite help but feel like they never get *quite* clean the way the hard plastic of the phone does.

So I said, "If I break one of the phones when it's out of its case, then I'd be happy to pay for it. I've got the money."

I smiled and laughed. Everyone else laughed.

Well, I thought it was everyone else. Apparently someone didn't think it was amusing, and decided that T should know about it.

The Union Rep asked, "Um, is this *really* all the meeting is about? Because that doesn't seem like grounds for a meeting."

T said "No, there's more"

"The perception of you is that you are very negative, and it is bringing morale down."

"Huh? I try to be friendly and professional"

"I'm not saying it's true or not true. It's a *perception* and this perception is making people unhappy."

"Can you tell me who, specifically, said this? Because I've asked around to see if I've been doing anything to make people mad and no one can figure it out."

"J has more details, and I'll ask him when he gets back."

At this point I'm thinking "Bullshit". Maybe it's T's perceptions that she's passing off as someone else's.

She then continued on to say that she knows that Telemetry wasn't my goal unit. And that none of us were hired by her, that she prefers to interview her own staff, and we were thrust upon her as much as she was on us.

Also, apparently, one of the Resource nurses came to her in tears because of how unhappy the new grads are.

At which point the Union Rep asked "Are all the new grads unhappy?"

"No, not all. Just most. I've had 4 people from the evening shift and one from the day shift say that they are happy here."

The Union Rep asked, "And what actions are you taking to make the rest of them happy? How are you trying to fix moraled on the unit?"

T more or less brushed that one off, saying that because we're switching to computerize charting soon, the higher-ups aren't listening to anything she says. I wonder if she realizes that's how we feel a lot of the time.

There was a lot more blah blah blah about how I am very vocal about not being happy on the unit and then the Union Rep asked if T had anything *good* to say about me. Which I appreciated.

To which T said "You're very smart, and you have good ideas. Like at the last staff meeting where you brought in pictures of things on the other unit"

Now, I don't want to sound cocky, but it's going to come off that way and I'm sorry: I *know* I'm smart. I've been smart my whole life. To tell me I'm smart is akin to telling me my hair is brown. Ok, that's nice. But it's how I am, not something I had to work for. I wanted to hear something like, "Her patients are happy with her care," or, "She's willing to help her colleagues when they need her." Something that I have control over.

Then she says something way outta left field that I didn't expect, "We could use more strong nurses like you on Day Shift. Some of the new grads aren't quite strong enough nurses and need more Med/Surg experience, and some of the transfers from other units are too stuck in their ways and unwilling to adapt."

"Would that be something you'd be interested in?"

Uh, bwah? So I'm negative, and I talk back, and I bring morale down, but you think I'm strong enough to bring a shift up?

I politely decline, stating that I am not a morning person, and would be useless till 1100. Meanwhile in my head I'm thinking, "You want me to wake up at 0500, work a shift that is *crazy* busier than PMs, *AND* take a $5/hr pay cut? Hell no. You must be on drugs."

Then she switched gears and told me that, more than anything else, this is like a conversation she'd have with her son. When she knows that he isn't living up to his potential, and she needs to spur him on a little bit. "Not that you're like my child or anything, it's just that kind of conversation." (She also mentioned wishing that other people would come to her when they are unhappy, rather than letting it get worse until the unhappy nurse's performance starts declining)

She said that I have a lot of influence on the unit because I am so smart, and that I have the capability of helping turn the unit around. She mentioned the suggestion box, and that no one had put anything in it.

Which isn't true, because the *day* I noticed that it was up I put in a suggestion to lower the box, which is high enough that I can't see the slot on top without standing tiptoe. I wonder if she even looked in it. I told her to check again.

She said that she wants me to be in a position like M and MH, training to be Resource/Break Nurse. I told her that they tried once, over a month ago, and pulled me after 45 minutes to take admits.

She told me that I need to be careful, because bad perceptions of people have a tendency to float around the hospital, and that all the units talk to each other. And if I want to have a chance at L&D, I have to make people like me and think positively of me, otherwise L&D won't want me.

And of course I'm thinking "The only reason I'm negative and miserable is because I'm *here* not *there*. AAARRRGH"

I tell her that I'm trying my best and that some days are better than others. As I wrote earlier, I actually had a good day recently. But I think one of these meetings with her takes away the equivalent of at least 3-4 good days, if that makes any sense.

So yeah. That's pretty much what I remember of it. I need to get better at keeping my mouth shut when I'm unhappy. And just keep swimming.

From June 3, 2009: Damn I'm clever sometimes....

2009-06-05T00:10:00.000-07:00

A mind-blowing *third day in a row* with the same patients.

One of them has the mother of all sinus infections, and is on some pretty strong antibiotics. Other than the infection, nothing's wrong with her.

In cases like these, we often set the patient up with a PICC line, which can stay in for up to a month or so (compared to 4 days for a regular IV line), so they can administer the strong antibiotics at home rather than being trapped in a hospital.

So she has signed the consent for the PICC but has a few questions. I re-explain what it is, and how they do it at the bedside (here is a great video of the insertion process) and that it's pretty quick and they numb you up, etc etc.

Judging by her reaction to the information, I'm not so sure they gave her all the information when getting consent. She said, "Maybe I don't want it after all."

And I'm thinking "How do I get her to understand and realize that it's not so bad after all?" and the little lightbulb goes off. One of my other patients has had a PICC for awhile now, and seems like a big fan of it.

So I excuse myself briefly and ask pt 72 if she'd mind giving a testimonial to pt 50 and her family. She says yes, so I grab 50 and her friend/sister(?) and bring them across the hall.

72 explains that it's really fast, and once it's in you can't feel it at all, and you can move your arm just fine. And the best upside is that you don't need to get poked for lab draws; they just take it from the port.

Pt 50 appears very relieved, and pt 72 wishes her good luck. I usher 50 back to her room, and pat myself on the back for a job well done.

From June 2, 2009: I had a surprisingly good day.

2009-06-05T00:01:00.000-07:00

It was one of those days where you amazingly get the same patient set twice in a row. And that particular patient set isn't terrible. Nothing short of a miracle.

I did all my pre-assessment setup (going through meds, printing telemetry strips, doing my PCHs) without any interruptions from patients needing a pitcher of water.

I managed to do my assessment and my charting by 1645. This is practically unheard of.

I actually got to take my first 15 minute break, and all my fingersticks were done when I got back. One of my patients was turned for me.

When I went off to dinner, labs were sent off, including a swab-up-the-nose I really didn't feel like subjecting the poor little old lady to.

When I got to take my *second* 15 minute break I thought I was dead and in heaven. It's rare to get one of my 15s, let alone 2.

Nothing exploded, there were no frantic calls to the doc for a medication that shows up from the pharmacy 4 hours later, and, this is the kicker:

I finished giving report 10 min before 2330.

That's right. I clocked out early.

It's days like this that I start feeling comfortable and happy with what I'm doing. I'm getting better at it. Just keep swimming.

Worrying....

2009-06-02T09:59:00.000-07:00

Before I went on vacation (which is why I haven't posted in so long) one of my managers took me aside and said "We need to have a meeting, so you should call the Union Rep."

I asked him what it was about and he said, "Don't worry. It's not a medication error." Ummm.... okay. I didn't ask what it's *not* Sigh. I ask for a little more information and he says that someone sent him an email about my behaviour. I'm very confused at this point. I have never had a patient seem to dislike me, and I am friendly and professional with my coworkers.

He says that I should try to arrange the meeting for before I leave. Hah. I have work every single day before leaving, and my flight the day I leave is at ass o'clock in the morning.

So I put it off.

I got back yesterday, and the other manager says, "We need to have a meeting about your attitude and behaviour. We need to have a heart-to-heart." Why does a heart-to-heart require a Union Rep? So I call the Union Girl and leave her a message.

I haven't gotten confirmation yet that she's coming. We're supposed to meet at 1515, so I have to call her again on my way in.

I've never had to deal with "office politics" before. I've never had anyone not like me enough to talk to a manager about it.

I've asked around a bit to see if anyone's overheard something. I wish I knew who it was and what s/he said. It's not so much that i want to confront the person, but it'd help me analyze my own shortcomings and improve on them.

Siiiiiiigh.

"Too many indians, no chief..."

2009-05-18T23:38:00.000-07:00

This was said by someone on my unit today, describing our management, and their poor leadership and communication skills.

I had an odd day today.

I get on the unit, see that I have 3 pts. Two are slated for DC, one is staying and is generally stable.

I am told that when I am down to one patient, I will take 3 pts from M so she can work on the computer training stuff for when we go electronic in a month. This makes little sense to me, as we all need to practice, so why not give my 1 to her, and then the next day she can do computer training. But whatever.

Pt 54 has had all his paperwork done and signed off, I just have to write the DC note and get him gone. He is getting picked up by Notoriously Late Transport Service. They give me a window from 1548-1618 that he will be picked up. He's anxiously waiting in his wheelchair in the hallway. I can tell he wants to GTFO. Around 4 I call the runner, and she comes to get him. She needs the CNA's help to bring his stuff, which includes a full prosthetic leg. Apparently the CNA also needs to hang out with 54 until his ride comes. But he's off my unit and I'm down to 2.

Pt 70 is waiting on his son to come get him. He is forgetful, and keeps asking about when he's coming and when he's getting his IV out. I've been told the pt can stand on his own long enough to pivot into a wheelchair. His son will be bringing his powerchair from home. Son finally comes around 1605 so we can go over the DC paperwork. I find out that he forgot to charge the powerchair enough to get it up to the unit, back down to the car, and back into his house. I assure him we can get a normal wheelchair to get him down to the lobby. We go over paperwork. Everything's all signed off, and I tell the son he should drop by the pharmacy on his way to the car to get his dad's meds. The son doesn't seem to believe me, though I tell him it'd be the best in terms of efficiency. I call the runner to come get the patient, and am told that since it's early enough, I can call the volunteers to wheel him down.

Volunteer comes up and I ask the patient how much help he needs in standing. He tells me he can't stand. I hate it when people misinform me in report. Argh. Frustrating. The volunteer tells me to call Lift team, and she'll come back when he's in the chair. So I call Lift for some stat help, and he shows up pretty darn quickly. Nice. I <3 Lift team. I should make a button for it. Anyhoo

We try to stand him up and get him in the chair, and Lift Guy notices that, sometime in the 15 min since I last saw the pt, he has had a lovely loose C-Diff stool. So out come the full gowns and I get to do a last-minute cleanup. To all you non-medical-professionals out there, pray you never have to deal with C-Diff smell. It's bad. Very bad.

Finally we get 70 into the wheelchair and call the volunteers again to get him gone. I think he left my floor at 1650. And then there was 1.

Going back in time slightly, I was hanging ABx for 71 at 1630, and overheard the MD talking about a small bowel obstruction, and possible surgery "tonight". So I file that into my head and go about my business. Not an hour later I'm getting a call from OR asking if I'm ready to give report on her. Ooookay.

I give report, and get going on the pre-op paperwork. Her daughter wants to be there before she leaves for surgery, but, in common fashion on my unit, she is whisked away before I have a chance to get things fully in order. And her daughter shows up about 3 minutes after the pt is wheeled down. I try to direct her to where the pt has gone. I have to assume she made it. I apologized profusely.

So now I'm zero. I'm seriously wondering at this point if I'm getting M's patients or not. it's about 1800 at this point. I ask J and he says I'll switch with M at 1900 so I should go eat dinner. I start getting cleaned up, and he changes his mind. I'll go on computer training instead. So I start on that. Something b0rks so I pop out to ask J about it, and Resource M says "You're getting patients! One admit, one transfer"

"Uh, bwah? J said I was on computer duty. Can you talk to him and figure it out?"

I hate having conflicting info from various sources. Kills me.

So we finally figure it all out, I'm on computer duty. Wheeee. As is M, whose patients are being taking by the 7-7 crowd. Mostly we complain about how dumb the system is.

I'm dreading the day we switch over to electronic charting. It's going to be disastrous.

Two half-days in a row....

2009-05-16T21:40:00.000-07:00

No real interesting stories lately, as I have been unexpectedly given the option to go home early two days in a row.

I know I shouldn't be taking so much time off. The reduction in pay will eventually catch up with me. And my patients weren't actually all that bad these last two days. I almost feel bad about leaving them after only 4 hours.

But there's still a part of me that goes "HOLY SHIT YEAH I'M GETTIN' OFF EARLY" whenever the Charge says "Hmmm... we seem to have 11 nurses on the floor at 1900, and only 21 patients."

On our unit, we're a mix of 8hr and 12hr shifts. So 1900 is a magic time, when a bunch of 12hr shift nurses come on, and the 8hrs who started at 1500 are still around. So I scramble to get all my ducks in a row in the 4 hrs I have to work with.

I guess this is really more of a non-post, as nothing of interest has happened so far this week. Though I am thinking about a Diabetes PSA in the near future. Stay tuned, I suppose.

We get a lot of patients who have fallen or are at risk for falling on my unit...

2009-05-14T10:43:00.000-07:00

So I am kind of intrigued by this article and video (sorry I can't embed the video directly, it's an ABC thing I guess) about a study done on women over the age of 62 to see what they do during the course of a slip/trip/fall and how to prevent from doing so in subsequent fall-risk situations.

From May 5, 2009: A New Personal Record!

2009-05-06T20:56:00.000-07:00

From start of shift to tears in less than an hour!

I'm getting *way* more efficient at this. lol.

The day started off rather well. Went out for lunch and margaritas to celebrate B getting the fuck off our unit-of-doom and going back to school. We'll miss her.

I get to work, get a rather half-assed report from a new traveler who I don't really know yet. One of the things I learn is that one of my pts is confused, came from ICU, and just pulled her IV when she got to the floor at 14:30. They managed to clean up most of the blood, though.

This is another situation where I can't accurately express all the crazy that was going on.

I go to the patient's room to assess, and she asks for a Diet Coke. We don't normally have soda on the unit, but I told her we could ask the kitchen to send some up with her dinner. She seems ok with this. I move along, but not long after hear her hollering down the hall. I go into the room and she is freaking out. Frantically trying to get her gown off, pulling her telemetry wires, etc. I tried to reorient her and calm her down, and keep her clothed. I told her we could take off the wires and everything but we should try not to give the whole unit a free show. She starts talking about her babies, and so I try to get in contact with her son, who isn't answering the phone.

I call the Dr and let her know what's going on, and she comes miraculously fast. She gets into the patient's room right as she's trying to pull her foley out. We manage to make her hold off for 30 seconds so I can grab a syringe to deflate the bubble. The last thing we need is her bleeding from the urethra...

Foley is out, Tele is off, IV is out, SCDs are off, and gown is barely covering her up. We get a sitter into the room while we try to get in contact with the family members. At some point while I'm at the desk the lady starts walking out of her room and BMing on the floor.

Then I get a rather miffed-sounding woman on the phone. Her father (another patient of mine) is back from ultrasound and has been on the gurney for a rather long time, and is getting uncomfortable (big guy....) and wants to get back in bed.

What the fuck is wrong with the runners? This has happened quite a few times. One of my patients is back on the unit and *NO ONE TELLS ME*. I can't read your minds, people.

So I was all kindsa frazzled from crazylady, and I made the mistake of looking at my watch. It was 1600 and by this time I usually have all my meds figured out for the shift, my to-do list is updated, I've done my PCHs, and am starting to assess. None of that's been done and I feel like I'm drowning.

That's when the tears start.

I feel like a dumbass because I know it's nothing I did, and crazy just happens sometimes. But I can't seem to calm myself down. So I high-tail it to the bathroom where I splash my face with cold water and try to look professional, with middling results.

So I get lift team to help me move big guy onto his bed. He barely speaks English, and I can tell he's going to be a needy sort. Sigh.

I scramble around trying to assess my patients and make sure they're comfortable, and by this time it's medpass time.

After I get done passing meds, I am standing at my "office" trying to figure out what to do with myself next. Big guy needs a blood draw, hip fracture needs to be turned, and little old asian guy needs 2 nasal swabs for flu/MRSA.

Then manager J comes and does something that completely surprises me.

He asks me what needs to be done (luckily I've just made a to-do list) and then says "Go on break. Take 45 minutes to relax, and get some of your charting done."

It was the shortest 45 minute break ever, but I got to decompress and catch up on my paperwork, and when I got back, *everything* on my list was done.

I managed to get all my stuff done on time, and transferred my hip fracture to the ortho floor. Well, I was told she would be transferring, and J decided to move her along without me finishing all my stuff (it was 2230 at this point) and brought her by the room I was in so she could say "bye" and I could wish her luck. I hope she does well. She's a sweetie.

And crazylady calmed down rather well once her family was there, and would likely be sent home in the AM if she remained stable. Happy to hear that...

The only crazy people I should have to deal with in the hospital are my coworkers :)

From May 1, 2009: Cool Dialysis Nurse and a Brief Update

2009-05-02T10:32:00.000-07:00

I was lucky last night. Out of my 4 patients, 3 were walky-talkies that didn't require too much care. 2 of them were set to go home tomorrow, so I pretty much just had to pop in every now and then to ask if they needed anything. My 4th patient, however, is a bit of a sad story. Little old lady, last year fell and broke her hip. They patched her up, and sent her back to the SNF (Skilled Nursing Facility) she lived at. While at the SNF the wound became infected. Badly. MRSA and P Vulgaris and one other bug I can't remember off the top of my head.

She'd been in a few times to get it treated with strong ABx but it didn't help. She was in ICU for awhile, and a couple days ago had an I&D and a revision, which took about 9 hours in the OR. It was like re-doing the whole hip surgery again.

Naturally she's in a bit of pain.

This woman moans if you so much as move her arm, which is odd cuz her arms are *fine*.... But I feel bad for what she's been through. She just wants to rest.

It came time for me to check her before-bed blood sugars ("HS fingerstick"), and she was in the middle of her first round of dialysis (kidneys not doing so well anymore). That can take a lot out of a person... literally lol

The dialysis nurse says "Wait, you don't need to poke her again" and grabs a TB syringe and pokes it into one of the ports on the "outgoing" dialysis tubing and draws me up a bit of blood.

I really appreciate him doing that. The patient was extremely grateful not to be stabbed again and I didn't have to do any finger-squeezing to get a good amount of blood out. Smiles all around.

On the Update side of things; I ran into the Union Rep in the hallway. She apologized again profusely, and said that she was really freaked out by what happened. After the meeting she went to one of her higher-ups and said "I'm obviously not cut out for this job, I didn't protect PurpleRN the way I needed to" and tried to quit. I think he talked her out of it, as well as told her that the stack of RRFs that J&T are painstakingly going over aren't their problem. They shouldn't have a single on on the unit. They should all be sent down to "Quality" for *them* to determine what's important enough to follow up on. It would be nice if they got a little payback....

I am Tired of Crying at Work -or- How Roughly $13 of This Paycheque Will Be From Sobbing Uncontrollably in the Bathroom

2009-04-30T01:44:00.000-07:00

So awhile back I screwed up. Hung a bag of D5W with 20K instead of NS with 20K. Pt wasn't diabetic, nothing bad came of it. Got written up as a med error. Had a nice long chat with the managers with a Union Rep present, did some crying for making a stupid mistake. Then nothing came of it and I moved on.

About 3 weeks ago I made another mistake. Pt was put on End of Life Care, and I'd never dealt with those orders before. I was being pushed to get the patient off our unit, since we don't deal with EOLC patients. The family member was pushing me to make the pt comfortable.

So I screwed up. Didn't do the orders right. Screwed up on med dosing. Made the patient comfortable though, and didn't overdrug. The family member thanked me for making him comfortable so quickly.

But it was another med error. So another meeting with the managers, with a Union Rep present.

These meetings are supposed to be short investigations into what happened. 15-20 minutes to get the full story. Instead I end up with a 45 minute interrogation, literally cornered in a tiny conference room. I wish I could remember all the things that were said.

I wish I could convey the tone in which they were said. The manager let J, the assistant manager run the investigation. He should not be allowed to do this ever again. The way he looked at me, the way he talked to me, it was like I was dirt. Why was I there, contaminating his Unit?

The first time I lost it was when he was demanding to know how I would avoid making the same screwup in the future. But it wasn't a simple "Now that this has happened, how are you going to avoid making the same screwup in the fuure?". It was a long, convoluted diatribe that ended with making me feel like there was no hope for me to do things right *ever* Man, I wish I'd recorded this. I know it's not coming across right and I'm sorry for babbling about it. But it's my blog, so there ya go.

I ended up having to call a time-out to cry for a little bit and get myself back together.

J and T ask a few more loaded questions, and babble about inconsequential shit for a bit, like the chain of command for various things. I'm pretty sure they just like hearing themselves talk, as they tend to say the *same damn thing* over and over in different ways. And they had the audacity to ask if I felt like I was being supported by them while on the unit.

But the kicker. The one that killed me.

It feels like the meeting of doom is finally almost over. And J says, "And you've got to remember, that with all of the orders and everything, the one thing you *should* be caring about is the one in the bed"

Something in me catches his tone, so I ask, "Are you telling me that I don't care enough about my patients?"

"That's what it looks like to me."

WHERE THE FUCK DOES HE GET OFF TELLING ME I DON'T CARE ABOUT MY PATIENTS?

I felt like I'd been kicked in the solar plexus. Every molecule of oxygen was sucked from my body and all I could do to get it back was sob. I have never cried like this in my life. My chest was tight and I was gasping, nearly shrieking, with every breath. All I could get out was "What the fuck? I am out of here. I can't handle this shit anymore. Fuck this. I'm out of here."

The Union Rep ushered me out of the conference room and into the bathroom so I could pull myself together. I felt bad for her. I am usually pretty stoic. But there are a couple things that really set me off. One is telling me that I am incompetent. The other is claiming that I don't care about something that I put my whole heart into doing.

She said she couldn't believe he said that. That she should have stepped in and stopped him in his tracks, but she didn't think he'd actually *say* what he said; she didn't think it was possible.

She said she'd talk to the Union higher-ups about what happened.

We have to go back in to officially finish the meeting. I ask if I can just go home, as I am, once again, "on committee".

J looks like he will say yes, but T says I am needed here for Very Important Work. But if the census stays the same then I can go at 1900.

The very important work of the day? Going thru everyone's charts to see when they had their last BM. I am dead serious.

1900 rolls around, and I am ready to GTFO. But no. The census is changing, and I will be the admit nurse. So at 2015 I get a new admit, and at 2130 I get another. At least they were easy admissions, and MH the Wonder Resource really helped me out on them. Sigh. Sorry MH for crying at you in the copy room. I'm working on keeping my shit together.

Everyone asks me when I'm transferring out of the unit. Trust me guys, I'm just waiting for an opening. Anywhere but here.

Woo unexpected day off!

2009-04-26T23:27:00.000-07:00

Yesterday we were overstaffed. Really overstaffed. Our 26-bed unit had 16 patients but the nursepower for 24. Therefore L and I were put "on committee."

Our tasks for the evening:

Get people signed off on the new way of printing EKG strips for when we go computerized.

Have people sign an attestation that they have read and understood a new law regarding medical record privacy (inspired by the Octomom fiasco) that says if we look at stuff we shouldn't be looking at we are subject to immediate firing and a fine up to $250,000 for each person's record that gets looked at.

Watch people pass meds and document if it's been done correctly.

Watch people give reports and document if it's been done correctly.

Check the new transfer patients' skin to make sure that if a pressure ulcer is already present that it's documented so we don't get blamed for it, and see if nutritional and wound care consults have been made.

Find out from our "fall risk" patients if they've been offered help with toileting or activities. The main issue with this was finding fall risks who weren't confused because they tend to forget that they've been up to the bathroom etc.

Restock the grey carts that are in the rooms on the B-side of the unit with useful things like saline flushes and 2x2s and IV-start equipment.

Restock the mobile rolling carts with the same.

This is all fine and entertaining for maybe half a shift. After that you start to get antsy. Especially with the paperwork audits. Those feel very useless.

So this morning when I woke up I called Staffing and said "We were rand ather overstaffed yesterday due to low patient census, and if the census is still low today I'd like to be considered for a day off".

About 20 minutes later my phone rings and my heart skips a joyous beat. Turns out it's just a friend of mine, calling to ask about some food she left at my place. Siiiigh.

Then I get a call about an hour later. It's Staffing! Yippee! They ask if I still want the day off. Hell Yeah! They asked if I wanted to use it as a vacation day (meaning I get paid for the day off). I don't need the money as badly as I need spare vacation days so I decline. (I'm enjoying my days of low expenses... not sure how much longer that'll last so I'm making the most of it)

My energy level went up immediately. From the weariness of knowing what's in store for me later in the day to the bounciness of an extra day with limitless possibilities.

Went for lunch with a friend, went to the mall to get bathstuffs, went hottubbing with some other friends, late dinner. Oh so glorious!

I'll always take a day without pay over a day on committee.

Another one bites the dust.....

2009-04-24T17:40:00.000-07:00

We all hear about the statistics that 1 in 5 (possibly more) new nurses quit within their first year. It's understandable, really. It's a high stress job that no amount of preparation prepares you for. It's easy to get overwhelmed. And when your management seems to be working against you at every turn....

One of the new grads who started with me finally put in her two weeks' notice. She's a really smart cookie and definitely competent as a nurse. But the pressure got to her and she snapped.

She was working 32 hours a week, and trying to go to school to get her degree in biochemistry. Back in March she asked the managers if she could cut her hours down to 24 per week so she could sanely go to school. Biochemistry is *not* exactly a light subject. They said no, it wasn't possible. They needed everyone to work more hours since we're short on people.

So she slogged along for a couple more weeks and finally said screw it and put in her notice.

When I used to see her at work and give her report, I could see the heaviness in her eyes, and feel the stressed-out aura around her. I can feel the same thing in almost all the new grads.

But this week when she came in you could tell there was a difference. The look in her eyes was positively zen, and the aura was serene. Having the end in sight seems to have boosted her spirit remarkably.

And I am jealous.

I want to feel calm again.

I wish I had the balls to say, "Fuckit, this isn't worth it." I think a lot of us do.

I was talking to another one of the girls about it yesterday and she said that she is learning to just say "Whatever" when something bad comes up. We discussed that the only way to survive this job on this unit is to just give up. Sigh, shrug your shoulders, and just keep on plugging away. Stop hoping for anything better because it's just depressing when better never comes.

What a way to view your job.

Just keep swimming, just keep swimming....

I love my job. I love my job.

*sigh*

Nursing Nightmares 2

2009-04-17T13:37:00.000-07:00

I had a rough shift last evening. I ended up staying an hour and ten minutes overtime because I hadn't gotten a chance to do a single word of charting. Everything just came at me nonstop all shift. So I got home around 0100, fell asleep a little after 0300. I had given my cell number to the oncoming nurses to let me know if I'd missed something or if there were questions.

Well at 0839 I get a call from one of the nurses letting me know that I'd somehow mislabeled the tube for a stat troponin draw that happened right around change of shift. I honestly can't believe I did that.

Anyway, I managed to fall back asleep and had this lovely dream...

I'm on the B station, waiting to get report. For some reason I'm sitting on J the Nurse Educator's lap, kinda leaning on him. He's a pretty snuggly guy. Talking to a couple of the nurses there, waiting for S to come give me report. She was a little ways down the hall so I flagged her down from outside rm 62 saying "C'mon, let's get this moving. It's already 1510 and I haven't gotten any reports yet." Someone unidentified said "Good job encouraging bedside report" so I felt happy someone noticed me doing the right thing.

Then S told me to follow her and suddenly I was driving to Santa Cruz (or at least the dream-equivalent). I think it was somewhere on campus. Anyway, I end up rather lost and at this rundown-looking shack, with a low wooden-post fence. I wander through the house looking for S, becoming more worried that I won't get through report on time.

I get back in my car and start driving around, and end up going through this large square archway in a wall, and what I see *looks* like ground, maybe with some water on it. I drive towards it and it apparently *is* water and I'm up to my chest in it in the car. But the car turns into some sort of floaty thing, like the kind you put babies in in the pool. The water is moving and I'm spinning around, trying to find my way back to the cement walkway near the arch.

I finally get out of the water and head back to the hospital so I can finish getting report from other people, assuming that I'll just figure out what I need to know about S's patients while I'm there.

I get lost a few more times on my way back, but I can't figure out what time it is an how late I am. At that point something in my brain says "Y'know, this seems awfully unrealistic. Are you sure you're awake and that this is happening?" I get back to the hospital and I try to ask MH and L if I really left the hospital and if any of this was real.

While waiting for an answer, Mom comes to wake me up so I can take her and Dad to the airport.

My most vivid/realistic dreams always happen when I have to wake up and interact with reality and then go back to sleep afterward. I'm sure this dream means something lol. I especially like the not-so-veiled reference to drowning....

Here's hoping for a calmer shift today.... [knocks all available nearby wood]

From April 15, 2009: Wonder of Wonders, Miracle of Miracles!

2009-04-16T12:32:00.000-07:00

Somehow, I managed to spend 80% of my shift with only *TWO* patients.

Let me tell you it was *heavenly*.

Our census was rather low to begin with (18 out of 26 beds) and I was given 3 patients. One of my patients was in for a lower GI Bleed and had it fixed up in the AM, and wanted to know what the plan was. Apparently the plan was a rather unexpected discharge! So he was gone *poof!* by 1700. I didn't even have to do anything, thanks to the ninja-like powers of the Resource, MH. So many things got magically done while I wasn't looking. Kinda crazy.

So that left me with 2 patients. They were on opposite ends of the unit, of course, but only having 2 of them left me with *plenty* of time to make the journey back and forth.

I kept expecting to get an admission or transfer, but somehow I stayed under the Charge's radar. So with my free time I helped L with her admission assessment and took other people's patients to the bathroom.

It was really awesome. Here's hoping for another good day, but I'm not holding my breath.

I had a good day today.

2009-04-13T02:34:00.000-07:00

Report was thorough yet concise. I didn't have any immediate pressing need-to-do's at the beginning of shift. I actually got a chance to make my to-do lists and properly assess my patients and even do my PCHs (Patient Care Hours, which are used to determine staffing for next shift).

My patients were all A&Ox4, ambulatory (though some with assist) and none of them needed 2-hour turning. They all smiled, even though one was pretty bummed about being in the hospital, and everyone said thank you. A lot.

And every time I asked the pt in room 60 if there was anything I could do for him he'd say "Just keep smiling, hon. Smiles are free." He was a good guy.

I had such a good day that I didn't mind that it took a little extra time to get the pt in 62 tucked into bed properly. She was so sweet and cute about getting the little adjustments made so it was *just right*.

The biggest problem I encountered during shift was a BP of 77/43 on pt60, and all we did was turn off his Lasix drip for an hour and keep an eye on him, because he was asymptomatic. The doctor I called about it was clear and understandable; even spelled his name out without me asking him to.

I didn't have time to pack myself a dinner for tonight, but one of the girls brought in cupcakes for easter. Dinner of champions. Someone else had brought doughnuts, so I feasted on sugar. It was glorious.

I listened to old 80s/90s music online all shift, and no one even looked at me funny when I was singing along.

And I got out early. All my everythings done on time, and report was quick. Out of there by 2318. I decided to just clock out because I'd rather have 12 minutes of freedom than 12 minutes of pay.

Here's hoping for a lot more of these to come.

From April 3, 2009: Nursing is a 24 hour job....

2009-04-10T21:27:00.000-07:00

The way our unit works, there are 2 different kinds of shifts. You have the new grads working 8 hour shifts (0700-1500, 1500-2300, 2300-0700) and everyone else working 12s (0700-1900, 1900-0700). Therefore there is often an overlap where for 4 hours (1900-2300) you have way too many nurses for the number of patients on the floor. On these days, *someone* has to go "on committee." Often it's the 12s, and for 4 hours they become extra Resources for us. Other times it's us 8s, and we end up doing audits (checking to make sure things were done correctly) and other boring paperwork-type activities. Or, like me, you can beg to go home early if you're not doing anything of actual importance. This means you have 4 hours to do all the need-to-do's that may arise.

So I had the opportunity to put in a half-shift, and I was pretty jazzed about it. I started off my shift with 3 patients, one needing to be discharged ASAP. I did my damnedest to get him off the floor, and off he was at 1615. Down to 2 patients. Yay. Oh but what's this? I get an admission at 1630. Admissions take *ages* to get in order, between the initial assessment with all its questions and the new orders and the MAR that shows up 2 hours later, etc etc etc. Luckily I had a resource to do the initial assessment because I had to get meds into my other patients. I'm also told that one of my patients needs to be transferred to a lower-acuity unit because she's no longer on tele.

While I'm working on my med pass, my manager walks by and says "By the way, Mr Worst Patient Ever will need a sitter." "Huh? When did you plan on telling me I was getting a transfer?" "He's being transferred to our unit and he's yours."

He gets to our floor at 1830 and I thank god he's a transfer, not an admit. I then find out that the other unit didn't do *any* of his 1800 meds before sending him my way. So I scramble to get his meds in him before I have to hand him off at 1900. The only thing missing is his pain med. Luckily he noncomplianted himself so badly he wasn't quite the same pain-in-the-ass as usual and didn't say a word. I just told him that one of his meds wasn't in the system yet and the next nurse would take care of it.

Somewhere in this time I manage to get some of my charting done. I don't know how.

Right around 1900 I get the MAR for the new admit but it's time for shift change. I apologize to the oncoming nurse (always apologizing... sigh) for not getting more done in my paltry 4 hours. I let her know about Mr WPE's missing med, and tell her that I didn't get a chance to go through my new admit's orders because the UA *just* finished with the chart, etc etc. She said "Well, I don't mind so much, just go through the med orders and sign them off so I can give the meds."

It's 1930. I'm supposed to go home. But I am green and don't want to rock the boat and alienate the seasoned vets, because they are all that stands between me and complete failure as a nurse somedays. So I sigh and start going thru the MAR.

I'm grumbling slightly to myself about not getting my stuff done on time when R leans over and says "You're choosing to be here." "Eh?" "You got to put your foot down. You're here because you want to be not because you have to be. Nursing is 24 hours. You got to remember that."

But the way some nurses look at you when you dare suggest that you ran out of time in your shift... It's enough to make you stay overtime so you don't have to see that look again.

Someday I'll put my foot down. Maybe.