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!
Monday, June 14, 2010
Tuesday, June 1, 2010
So Pissed!
I know sometimes doctors make bad decisions. But the same thing happened *twice* in the last week, and I don't want to have to deal with this nonsense!
So on Thursday I get a transfer from our Ortho floor around 1600, right at beginning of shift. The guy had had a fall, broke his tibia, nothing too exciting. He was coming to us for more monitoring, as he'd been having trouble breathing. Now, we can't do anything extra for shortness of breath that they can't do on the regular floor. All we can do is keep continuous watch on his EKG and pulse ox.
So he gets to me, and he's not lookin' too good. Breathing pretty hard, and asks for the bed to be sat all the way up, plus an extra pillow behind his back. I call RT immediately to get him a treatment, because I can hear his wheezing without a stethoscope. I call the doctor, and he decides he's probably fluid overloaded and orders 80mg of Lasix IV, along with a drip.
I'm thinking he's gonna wear out soon enough, with how hard he's breathing. He really should be on a BiPAP, which can't be done on our unit. But we decide to give the Lasix a chance to kick in. One hour later, there's only 75mL of urine in the catheter bag. Not a good sign...
Somehow in the course of all this, the appropriate people for an RRT show up. Not sure how, cuz I didn't call them lol. All of a sudden, orders are popping up all over the place. So we work on getting an ABG and one doctor decides we need to draw labs for starting a heparin drip, because the dyspnea could be caused by a PE which is a known post-op risk.
Before I know it, around 1745, he's headed downstairs to Stepdown. He eventually ended up intubated in ICU for a night. We knew from the moment he got to our floor, that he would end up leaving us very quickly. Why didn't the doctors see it?
Then today, I get report on a patient coming from the Oncology/Medical floor across the hall from us. Came in with pneumonia awhile back, spent some time in ICU, then stepdown, then to the normal floor. Over 90 years old. Family is insane, calling one of our sweetest doctors "the grim reaper" because she brought up the topic of palliative care and hospice. Patient is, of course, full code, and the son cannot be persuaded to change his mind, and becomes hostile at the suggestion.
The nurse giving me report said that the patient looks *bad* and that she will probably end up going to stepdown or ICU in the near future. The RRT nurse who showed up at 330 wrote in her note "Recommend pt go to stepdown." But no, the docs send her to our floor. Where all we can do is watch her struggle for every breath. Even after I tell my manager and he calls the appropriate people.
So she shows up on our floor around 2030, wearing a non-rebreather mask. She's satting 100%, but her RR is 32 and she's using all her strength to keep going. She's able to nod yes/no, and can say maybe 1-2 words. But she's exhausted. I'm thinking "why the hell is she here?"
I call the doc, and stress that she doesn't look good and that maybe she should go to stepdown. The doc says that they are trying to avoid another ICU stay, and she wants to try her here first. She promises a visit in about 45 minutes.
The docs show up, and immediately order an ABG, and put in a transfer request to stepdown. And I'm thinking "Why do you keep wasting my time, and jeopardizing the patient's safety?!"
I give report, and by 2230 she's headed downstairs while I frantically try to get all my charting and notes done by end of shift.
Dear Doctors,
Telemetry is not a magical unit. There are a couple extra heart medications we can give. And we can monitor EKGs and pulse-ox continuously. But in terms of breathing, we are incredibly limited. We can only use CPAP, which doesn't help someone seriously struggling to breath. All we can do is watch and wait and hope things don't get worse.
Therefore, I have a request to make of you. Please. Listen to us. If a nurse suggests that a patient is better suited to another unit, it's not just us trying to get out of taking another patient. We want our patients to be in the safest place.
If you are planning a transfer to higher level of care, and you are debating between two different levels, please, please, please, send the patient to the higher level. Worst case is that they get too much care. People can always be downgraded if they get better. But if a patient is sent to the lower level of care of the two, valuable time is wasted, putting the patient at risk.
I don't want to have to do go through this scenario again. Listen to your nurses, and err on the side of caution. That's all I'm asking.
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...
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...
Saturday, April 24, 2010
This has been a glorious week!
Of the four days I was originally scheduled to work this week, I've only done one and a half.
I was unexpectedly called on Wednesday to see if I wanted the day off. Hell yeah!
On Thursday, I was given the opportunity to go home after 4 hours. Hell yeah!
And today, I called to see if there was any chance they were overstaffed and didn't need me. Ask and ye shall receive!
Thursday was a fuckwad of a hard day. We only had 4 RNs on the floor because our census was low. According to Papa, that means that we technically only need one RN to be both Charge and Break Relief. I dunno if he's ever tried to do both at the same time, but it is *not* safe.
As Charge, you're the one who does the assignments and works with the house supervisor to figure out beds and nurses for incoming and outgoing patients. As Break Relief, you are to take over a nurse's patients during her scheduled breaks, and care for them as if they were your own.
This is nearly impossible when you've go the House Sup calling you every 10 minutes asking if you have a new bed available. Especially when you technically don't have any nurses to take patients yet, but you will after 1900 when the Night crew comes in, so you have to try to plan for the future. Meanwhile one of the patients is desatting to the mid 70s and the alcohol withdrawal pt with a history of seizure is complaining of a headache and needs pain medication. And the calls keep coming in. 84 year old with syncope from ED. Transfer of small bowel obstruction from stepdown. Pt coming from post-op who had an anaesthesia complication.
I dunno what dumbass came up with the rules, but he obviously hasn't ever tried to do 6 things at once, safely, before.
By the time 1900 rolled around, I was ready to throw my phone out the window and rip off the head of the next person who asked *anything* of me. Technically everyone got their breaks, and the assignment did get done (3 times.... every time I thought I was done, I got the call for another pt coming in). But it was more stress than the extra 5% an hour is worth.
When I got today off, I decided not to be a lazy bastard and went on a 9 mile bike ride with my boyfriend. It was awesome. I think my goal is to go on a ride at least 2x/week. One of the girls at work is 3 months pregnant and still skinnier than me... this must be dealt with.
Wish me luck!
I was unexpectedly called on Wednesday to see if I wanted the day off. Hell yeah!
On Thursday, I was given the opportunity to go home after 4 hours. Hell yeah!
And today, I called to see if there was any chance they were overstaffed and didn't need me. Ask and ye shall receive!
Thursday was a fuckwad of a hard day. We only had 4 RNs on the floor because our census was low. According to Papa, that means that we technically only need one RN to be both Charge and Break Relief. I dunno if he's ever tried to do both at the same time, but it is *not* safe.
As Charge, you're the one who does the assignments and works with the house supervisor to figure out beds and nurses for incoming and outgoing patients. As Break Relief, you are to take over a nurse's patients during her scheduled breaks, and care for them as if they were your own.
This is nearly impossible when you've go the House Sup calling you every 10 minutes asking if you have a new bed available. Especially when you technically don't have any nurses to take patients yet, but you will after 1900 when the Night crew comes in, so you have to try to plan for the future. Meanwhile one of the patients is desatting to the mid 70s and the alcohol withdrawal pt with a history of seizure is complaining of a headache and needs pain medication. And the calls keep coming in. 84 year old with syncope from ED. Transfer of small bowel obstruction from stepdown. Pt coming from post-op who had an anaesthesia complication.
I dunno what dumbass came up with the rules, but he obviously hasn't ever tried to do 6 things at once, safely, before.
By the time 1900 rolled around, I was ready to throw my phone out the window and rip off the head of the next person who asked *anything* of me. Technically everyone got their breaks, and the assignment did get done (3 times.... every time I thought I was done, I got the call for another pt coming in). But it was more stress than the extra 5% an hour is worth.
When I got today off, I decided not to be a lazy bastard and went on a 9 mile bike ride with my boyfriend. It was awesome. I think my goal is to go on a ride at least 2x/week. One of the girls at work is 3 months pregnant and still skinnier than me... this must be dealt with.
Wish me luck!
Monday, April 5, 2010
Our Easter Miracle....
Today was an aberration to be sure. I woke up at 0700 to go to Easter breakfast at a friend's house. Then I got in trouble at home for missing Easter brunch with the family. There is nothing worse than disappointing my Mom. I was feeling pretty down and guilty when I got to work.
Imagine my surprise when I saw the board: the gods saw fit to reduce our census considerably. We were at 14 (I was kinda pissed off at the beginning, as I'd called to see if I could have the day off and didn't get a call back...) beds filled until near the end of shift when we went alll the way up to 16.
The miracle is that were actually appropriately staffed. More than expected, really. Not only did we have a Charge, I was Resource, and we had *two* CNAs. With only 14 patients lol.
And the RNs on the floor seemed to have everything under control, and most of them refused their 15 min breaks saying they didn't need them. I practically had to beg to take phones away at least so they could do things uninterrupted.
I ended up busying myself cleaning the med rooms and restocking the IV start kits, which were in a horrible state of disarray. Dear Unit: MRSA swabs are not part of the IV start kit. Tele stickers are not part of the IV start kit. Suture removal kits are not part of the IV start kit. Also, urine specimen tubes do not go with the blood draw kit. Just saying... Please try to keep them nice for at least a little while!
I got to take someone down to CT, didn't get lost, had a nice chat with the Radiology Tech downstairs. I figured it would make the most sense just to stick around during the scan rather than go up and have to come back down again later.
There's not much point to this post, I suppose. I hope I get patients tomorrow so I can be in my own little world...
That is, if I can't get the day off... :)
Imagine my surprise when I saw the board: the gods saw fit to reduce our census considerably. We were at 14 (I was kinda pissed off at the beginning, as I'd called to see if I could have the day off and didn't get a call back...) beds filled until near the end of shift when we went alll the way up to 16.
The miracle is that were actually appropriately staffed. More than expected, really. Not only did we have a Charge, I was Resource, and we had *two* CNAs. With only 14 patients lol.
And the RNs on the floor seemed to have everything under control, and most of them refused their 15 min breaks saying they didn't need them. I practically had to beg to take phones away at least so they could do things uninterrupted.
I ended up busying myself cleaning the med rooms and restocking the IV start kits, which were in a horrible state of disarray. Dear Unit: MRSA swabs are not part of the IV start kit. Tele stickers are not part of the IV start kit. Suture removal kits are not part of the IV start kit. Also, urine specimen tubes do not go with the blood draw kit. Just saying... Please try to keep them nice for at least a little while!
I got to take someone down to CT, didn't get lost, had a nice chat with the Radiology Tech downstairs. I figured it would make the most sense just to stick around during the scan rather than go up and have to come back down again later.
There's not much point to this post, I suppose. I hope I get patients tomorrow so I can be in my own little world...
That is, if I can't get the day off... :)
Friday, April 2, 2010
Dear Grateful Patients and Family Members...
We, your nurses, love knowing if you appreciated our care. There is nothing that gives me the warm fuzzies like a little old lady saying, "You're so sweet and caring. Such a wonderful nurse." Makes me forget that I hate my job sometimes.
But I have a favour to ask of you. I know I probably don't speak for the majority, but for myself, I have this tiny request.
Stop it with the baked goods already!!! Why does "I enjoyed your nursing care" automatically have to translate into piles of cakes and cookies in our break room? I'm trying to lose weight for god's sake!!
I can turn down a box of chocolates, or distribute them among coworkers. But I am powerless against homemade lemon squares, or chewy chocolate chip cookies. And nothing goes down quite so nicely after a hard shift like a cup of tea and an almond biscotti that just happens to be sitting on the break room table.
It's instant dopamine gratification, and it needs to stop. You will make me diabetic, I am sure of it.
If you want to show your appreciation, I'd love it if you filled out one of the comment cards we have at the nursing station. My boss sees those, and I need all the good words with her that I can get.
Thanks,
PurpleRN
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
Monday, March 22, 2010
The ugliest rhythm I have seen so far in a person who wasn't actively trying to die...
I had a patient yesterday who was 81 (but looked much much younger) who was A-Fib brady (in the 40s, 30s when sleeping) with a bundle branch block and a long QT interval.
Needless to say, pacer pads were nearby....
Needless to say, pacer pads were nearby....
Thursday, March 18, 2010
It always happens at shift change, right?
So after a busy but not-too-hectic evening, I finally sat down around 2245 to finish up my charting.
I had a lot to catch up on, because of a new admission to 63. He showed up on the unit around 1800, but was immediately whisked off to dialysis before I had a chance to do any assessment beyond "He's alive, A&Ox3, and doesn't look like he should be in the hospital." He came back to the unit around 2130. I did my admission sheet, got him dinner, and brought him his (late b/c of dialysis) meds in record time, done around 2230. He was doing just fine all through it.
So at 2250 his wife comes up to the desk with a worried look and says, "My husband is not acting normal at all. I need you to come take a look right now." She said it with such calm and straightforwardness that I was immediately terrified. When people come at you with histrionics it's usually something stupid like needing a repositioning. When there's an eerie calm, you know there's trouble.
I popped my head into the room, and he's staring off to his left, with a right-sided facial droop that I didn't recall seeing 20 min earlier when I was last in the room. We asked him to say his name, and his speech was slurred and unintelligible. He was able to lift his left arm on command, and give my hand a good squeeze, but we couldn't get any response from the right hand side. Couldn't even get him to turn his head that direction.
"Well, shit" I thought.
So I called the on-call doc and asked her to get up to us to check him out. Resource came in to check his vitals, which were fine. We decided to call RRT to get a little extra help.
Doc showed up a little before 2300, we called a Stroke Alert about a minute later. This involved doing an assessment on pronator drift, and getting a bunch of blood samples.
The lab had been in not too long before and said he had "slippery" veins. They weren't lying. Luckily, he had an 18g in his forearm with brilliant blood return that we were able to get samples from. Thank god.
He was off the floor and down for a head CT by 2313, which isn't too bad, timing-wise. Things seemed to move much more quickly, and I was always surprised when I looked at my watch.
His poor wife was rather shocked, because this wasn't what she expected at all. Hell, they were going to send him home from ED earlier that day. Got him dressed, took out his IVs, everything. Then they changed their minds and sent him up to us.
So after the CT they sent him to ICU, and I had to wait awhile to give report to the nurse who would take him. Hooray for overtime!
I was told by Pappa that they did find a couple blockages on the CT and he was eligible for tPA.
I'm curious to see how it all ends up when I go back to work today.
Addendum: So apparently they didn't do the tPA after all, owing to the severity of the stroke and how many areas it involved, as well as the fact that the pt was a Jehovah's Witness. If there were bleeding side effects from the tPA, it would be very problematic if he didn't accept transfusions. He is stable now, transferred to our neuro unit, already able to swallow safely and working on his communication skills. Apparently they called an erroneous code blue on him yesterday when he had a seizure post-dialysis. Luckily he's still okay.
Well, okay as can be expected....
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....
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