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

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

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

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




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

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

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

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

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

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

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



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

Step one in solving our healthcare crisis...

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

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

A quick laugh

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

WNL = We Never Looked

Short, sweet, and totally true half the time lol


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

I'm still hoping for my TriCorder...

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

Dear Patient in 63,

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

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

Knock it the fuck off!

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...

"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...

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...