A rare slow night in the ICU...

On a night this relatively slow, we sit around and try to outdo each other with Nurse's Grossest Hits. Finer points of this conversation included scabies, leech therapy, and a patient who ate from his own wound. (Nobody could top that one.)

Then I started messin around with the ultrasound, because it was there. Then we were all dopplering various pulses on each other. This led to breakin out the train of four to see who could tolerate the highest setting. (On our arms, people...my unit is almost always co-ed, and David is married and that wouldn't be cool.) (I can tolerate a 7 on my ulnar.)

If I'm gone for awhile, it's because in the last four mind-numbing hours here, we broke out the defib pads for fun.

We're talkin about slappin the train of four onto the meth patient we did admit tonight. That actually sounds like more fun.

Because that nice, sweet nurse that's taking care of you is actually evil.

Things that crack me up about Press-Ganey

Many other nurses and docs have blogged about Press-Ganey and the appropriateness of the measuring sticks the organization has chosen to evaluate "good" care in the hospital. Sane people want accountability in health care, and JCAHO does not provide that sanity. Patient satisfaction surveys were inevitable. However, choosing useful measuring sticks for 'good' can be problematic.

What is a 'good' hospitalization from the patient's perspective? A patient with a total knee replacement has a wildly different view of 'good' hospitalization than the patient with an acute psychotic break.

You will not find a serious discussion on this in my post today.

Instead, the following chosen criteria cracked me up. Hospitals are evaluated on the following:

* Percentage of patients who thought their nurses "Always" communicated well.
* Percentage of patients who thought their doctors "Always" communicated well.

There is a world outside of Oz. In this world, my patients look like this:







Sidenote: We had a guy two weeks ago who threw a snowball of poo 15 feet outside of his room. What was most impressive about that is that his hands were tied down at the time.




* Percentage of patients who "Always" received help as soon as they wanted.

Nurses love this measuring stick. I understand the need to ask a question like this on a patient satisfaction survey. However, the gap is that the question does not account for the fact that the patient is not the best evaluator of the professional RN or MD's priorities. Jane and John Doe are so ignorant of the workings of the health care system and the professionals within that system that they simply don't know how much they don't know. They do not understand how insignificant their desperate need to pee becomes in comparison to the often more critical needs of other patients. Most patients will desist on the call light if they hear the loud noises and see flashing defibrillator paddles, because that's what tv tells them saves lives.

But most will still answer the surveyor's question with 'No, I didn't actually get to pee the second my bladder twitched cos there weren't enough nurses to help me get up to pee and while the other nurses were tryin to get a pulse on that other guy.'

Some great rant examples...please see: Madness of an ER nurse, ERNursey, ERMurse, my friends in the UK at Mental Nurse, a new blogger I found at ER-Life.



Personally, I don't know what the big fuss is about. I always put mints on my pillow, bring fries with that and ask grieving families whom I have counseled through the death of a loved one if they'd fill out a satisfaction survey to let my boss know that they liked me.



* Percentage of patients who thought their pain was "Always" well controlled.

I love that one. Open-heart surgery won't hurt a bit, sir. We will keep you totally pain-free all of the time. All this making you not dead won't hurt a bit.



And as a NOC-shifter, I love this one, too:

* Percentage of patients who reported that their room was "Always" quiet at night.

I had a guy once who was pissy about all the "damned noise happening down the hall." I admit I was fried, having just come down the hall from the ugly code that was happening. It wasn't my best night. So instead of being all soothe-y and pillow-fluffy and sympathetic, I was human. I snapped at him: "I'm sorry, did that woman dying DISTURB your beauty sleep?"

I'm sure he complained about me on his patient satisfaction survey.

....

What's stunning about this website isn't that such a tool should exist to evaluate hospitals. After all, baby boomers want to know the cushiest hospital in which to receive their joint replacements because their bottoms have gotten too large for their knees to support any longer. I'm really okay with that, with economic natural selection.

It's the choice of some of the measuring sticks that Press Ganey utilizes.

It's the lack of context in which real illness actually happens. We in health care know that it's nothing like on tv. The public really doesn't.

It's the clash of capitalist economics and socialist economics: we want competition to weed out the better provider of service, but we also need to take care of the elderly, the drug- and alcohol-addicted (and their children), the sick who belong to a low-income tax bracket, the middle income bracket who can't afford the copays until it's too late.

Press Ganey's survey is not a bad idea. It chose some strange rulers. Today, I'm only ranting.

The real issue is that I'm wondering what some better rulers would be.

Just a snapshot.

The ER shipped a patient up tonight, GI bleeder....vomiting copious blood. The patient appeared ill, like he'd been ill for years. All he wanted was some pain medicine and to have us let him die. That's what he said in the ER. His family said, "Yes, this is what he wishes. He's told us so."

We didn't have a formal DNR. And I have no clue why the ED shipped him up to the ICU, instead of following his wishes right then and there.

Dr. One Of The Good Guys, one of our intensivists, was here. The ICU team gathered at the bedside and Dr. OOTGG shakes his head.

"Give him some morphine."

It was quiet and simple and we did what the man wanted, and the line went flat.

And that was that.

Change of Shift is up!

Over at Parallel Universes. Check it out.
/jo

Another turning point in Jo's career....Of Magnet, of autonomy, of managing my license like a business

MyHospital (let's call it 'MH') is working toward Magnet status, and I anticipate this effort will be ultimately fruitless. I have been part of my Nurse Practice Council (NPC) for 18 months before I sent in my resignation on Saturday. I started the ICU's NPC with my co-chair, G. G resigned Monday. Several nurses on the ICU committee are also abandoning it now, too.

I'm not interested in telling you specifics, and MH may find an arbitrary reason to fire me if I do. (Not that I find this bothersome...I'm an RN, for chrissakes. How many RNs among you have gotten flyers/emails/recruiter taps in the past month?) Besides, the specifics of MH aren't interesting.

The point is that I believe MH has parsecs of vacant emptiness between the offices and the bedside. It doesn't appear to matter that some of those offices contain people who have sat for, and successfully passed, the NCLEX. No understanding appears to exist between the two. No honest conversation happens in both directions, it's radio broadcast from one side only.

I needed to get involved. I came from the consulting world. You hire a consultant for your organization to come in and identify the root of your organization's effed-up problems for you. They recommend changes, they help you implement the changes your organization can tolerate and they leave when the problem is resolved or at least tolerable. This suits my mentality. I am not interested in bandaids. I am interested in resetting the bone.

I believe this to be true of most bedside nurses.

It was natural of me to find stupid things on my unit, within the organization at large and try to become part of the solution. I observe the direct correlation between your overtime dollars timed to the implementation of your ludicrously obfuscating computer charting system, for one example. And I say you made a blunder of enormous proportions that can be salvaged with the more than willing cooperation and collaboration from the bedside.

But such observations are unpopular among administrators at MH. I was hauled into the principal's office for that one. (Remember when Linda Blair's head spun off her shoulders? Yeah. Dude, you should have seen it.)

But I can't do this anymore. It's not that I met a brand new managerial howitzer that is pointing directly at me and my partner, G. It's that the meeting was the last shred of proof to me that it's no longer worth the fight.

I'm not even sure if I believe in that Magnet crap, anyway. I only believed in the ability to work to improve things for my patients and my colleagues. I am afforded less and less an opportunity, as the tools of divide to conquer and fear of arbitrary reprisal are pulled out. As my friend, a charge RN (read: quasi-management), makes a sincere attempt to mediate and is told to 'keep her nose out of it'.

Another friend is talking to a recruiter. A third is now picking up shifts at a sister hospital. A fourth has switched to part-time. Etc, etc. The experienced nurses leave my unit, leaving an ICU full of cheaper new grads who don't know defib patches from pacer pads.

...

So now. If I'm mentally checked out of trying to fix the bureacracy from within, I'm left with what my next set of goals are. I'm the kid of person to grow in the job I've got until I've gotten all that I'm interested in getting from it. Then I find a new place to grow. I'm just started growing in the ICU, and I'm comfortable there. I know everybody; the things I know, I know well. I learn something new every day. I know the docs, work well with the majority. I'm friendly with the pharmacists; when I send a med-gram for drugs I need, I get them (a bit unfairly) fast.

But there are a lot of ICUs in town, and they might be interested in having some more prn nurses.

Considering looking at Jo, RN, as a business. A business needs to have something to offer (which I do), be fiscally sound (and there's certainly several ways I can improve that). And a good one continues to grow, refurbish, repolish, try new tools, new skills.

I love my unit, because I really care about the people there. It's one of the most fun, interesting curious bunch of people I've ever worked with. I'd rather not leave.

But a business can, and maybe should, have more than one client. Maybe I need to consider that, too.

...and then there are good days.

Today's patient:

Patient came in on a cardiac alert. Massive MI, cored twice, once in the field, once in the ER...sent him to the cath lab and now he's with us. Cath lab guys roll him over to us, and he's crackin Monty Python jokes, talks about how great it is to be alive. Positively *giggling*. Says how lucky he is, how thankful he is to the paramedics and the nurses and docs downstairs, to cath lab, to us. Can't believe how good it is to be alive, where are his children? Can he see his wife soon?

I love that.

Some days? People are .....good. There's good reason to help them get well.

The myopia of Dr. Surgeon.

This is an addendum to my story about Margaret, my patient from earlier.

True story:

Jo has parked in Margaret's room because Margaret requires 1:1 RN care. She needs the titrating of vasoactive meds, dialysis, ventilator tweaks. She wishes to have "life support" care withdrawn 36 hours from now. She'd had a complex vascular surgery the previous week, done by Dr. Vascular Surgeon, to improve the circulation to her legs and feet. She is 84.

Dr. Vascular Surgeon walks into room Monday morning at 0700. He and Jo exchange polite good mornings.

Jo: "I have some concerns I'd like to share with you about how Margaret's doing, once you're ready to hear them. Here's her chart if you'd like to look at it first." I hand him the chart.

Dr. S thanks me, leaves room with chart, comes back five minutes later. He looks at (but does not unravel) the dressing to her leg. "When did you change this last?"

Jo: "At four this morning."

Dr. S: "And how are the incisions doing?"

Jo: "Well approximated still, no signs of infection, her white blood count is still within parameters, some moderate serous oozing from the groin, mild from the leg." (No, really, I sound like this.)

Dr. S: "And her pulses?"

Jo: "I can doppler the PT's intermittently, but can actually palp the DPs. That's a new finding from last night, days wasn't able to find the PTs and could only doppler DPs on their assessment."

Dr. S nods, and covers her feet back up without confirming my findings. I'm sure that his note will record what I said verbatim. I guess it's nice to be trusted? As he washes his hands, he asks, "What are your concerns?"

Jo: "We've been unable to titrate her oxygen much lower, and her rate is remaining 7 to 10 over the vent despite the 40 mic's of propofol. Also, I've been unable to get her off that point five of dopamine. Her pressures are stable, despite the fairly high blood flow on dialysis."

Dr. S cuts me off: "I'm just the surgeon."

I glare. Jo: "Also, though she's on the propofol, we have nothing for pain. Maybe a little Fentanyl? And I can back off on the propofol?"

Dr. S: "Well, she shouldn't be having any pain since the surgery was X date. Looks like that's healing fine."

My. jaw. drops. I make a wide gesture to the room, to the machines. "How about the REST of what we're doing to her?"

Dr. S is drying his hands, pitches the paper towels and shrugs. "I'm just the surgeon."

He walks out of the room, and there's Jo, still got her arm dangling pointlessly in the air.

If you haven't seen this, you need to:

This is how, in a pandemic, those who are treated medically and those who are not treated will be chosen: AP story.

Triage is tough. Medical professionals do it every day, and to the layperson it probably sounds horrifying.

Many decisions are hard to make. And some just aren't.

I'm not an uncaring person. When the pandemic finally comes, SARS or avian flu or whatever, I will work the overtime at the hospital. I've been one of the people who did the overtime through three blizzards, sleeping (or not) at the hospital during the days. I remember one day I took care of sixteen quad- and paraplegics for a sixteen hour shift, with my partner, who did the other sixteen.

I'm willing to do that when a crisis happens, like millions of other nurses are. We are caring people. I love the geriatric population; I knew I wanted to work with older people from the start of nursing school for me. I hated my ped's rotation. But in a triage situation, and all other things are equal? I'm gonna treat the 10 year old in respiratory distress before I get to the 70 year old in respiatory distress. I think we're hard-wired as a species for some decisions.

It might not be a bad idea for the public to know that, though.

I love MICU: reason #1

I realize the past few posts have been harsh and negative. But there are a lot of nights I do love my job, love the ICU. So I'm gonna tell you about when I love the ICU.

Reason #1 is The ICU means Intensive care...

We do have the classic drama like on tv, (only always in the ER...the ICU does not have its own tv show.) I was there for our last cracked chest in the ICU...which does not happen in the ER. A suture on the junction from the pt's aorta to her heart muscle tore. Blood. Everywhere. Liters and liters of it. God, it was bad.

And tell me why don't we have our own tv show? Not that the ED isn't interesting, it very much is. But. But. The ICU is cool, too.

They don't have situations like my patient the other night in the ER.

Margaret is not my patient's name, and she's a train wreck. She came in for a complex vascular surgical procedure, developed a bleed...and 36 hours later she's in multiple organ system failure. Yeah. That fast.

In ICU, you meet patients at a life-or-death time of their lives. Margaret has in her living will that she does not want to be on life support for more than seven days. Today is day five. Don't think that isn't at the forefront at my mind at all times. A week ago, she was living at home independently. Having cups of coffee with her friends. Visiting with her grandchildren, walking her poodle. This was a scheduled, planned, surgery.

On this particular patient, we don't have an intensivist or hospitalist, so there is no one single MD brain drivin this train. It leaves a lot of holes for the RN to fill. I'm not going to blog on the appropriateness of this (it isn't) right now. What it does mean is that the day RN with whom I'm swapping this patient every day (Douglas) and I are operating in a frustrating vacuum. And a clinically challenging one.

What I do love about taking care of this type of patient is that I was busy all night titrating drips, titrating the vent, titrating the CRRT, getting the next round of labs and futzing all over again. Dressing changes, lab values to interpret, arterial and central venous pressure line waveforms to futz with. Oh, and she has a paced rhythm, too.

...I can't seem to get Margaret off the dopamine, even with cutting her CRRT rate in half. Her central venous pressure is THIRTY, and I'm slurpin out fluid at almost hemodialysis rates. But I stop that, hold the whiff of dopamine I'm giving her, her pressure tanks. Her heart likes the inotrope. Weird. (Gee, I wish I had an intensivist here who might have some more ideas on what's up with that....)

Incremental success for this patient is decreasing her oxygen by 5% and having her tolerate it for an hour. Five percent is no piffle. It will be the difference between whether or not she can attempt to wean off the machine, i.e. recovering or not. I am continually testing how her body responds to the changes in the meds, changes in the amount of fluid I'm pulling off her body, in the vent settings.

Let me underline: We have two days left to fix her. Before the family draws the line because of Margaret's previously stated wishes. If we can't fix her, we will stop the kidney machine, take the tube out of her throat and she will essentially....drown. In her own body fluids. Of course we're gonna have pain and sedation meds on board, but I realize how horrible this is.

We have 48 hours. Where else but in the ICU do you have this kind of situation?

In the ER, some of their adrenaline comes from the chaos, the randomness, the wildness. 'Turn and burn' is what the ED nurses tell me. It's a different adrenaline in the ICU. Continuous dose adrenaline, maybe. Adrenaline for control freaks (wonder if the OR is like that, too?) I didn't sleep well today, because I was thinking about what I may have forgotten, what I could have altered or improved.

I don't know Margaret. I see the pictures of her in her room. But my head is totally wrapped up in what we need to do to help her body heal from the inside out. Why the drop in crit this morning? Where is the bleed? Do we need to give her platelets because the CRRT is chewing them up? Why can't we get her off that blasted dopamine? Why is it sometimes I can doppler that left post tib, and sometimes I get it on the right but not consistently? What's going on with those sutures in there? Why are her LFTs still high even after we've stabilized her pressures? I wish I had a PA cath to see what's really happening with her hemodynamically. Her lungs DO sound better, but when she turns to the left, her sats drop, I wonder if we don't have an infiltrate on the right? Her CRRT "arterial" pressure kept alarming negative pressures, which might imply that she's vasodilating...etiology? Sepsis? No, we have her on enough abx to sterilize a barn. What are my other types of shock: spinal, no, anaphylactic, no, cardiogenic shock? That's the only one left...? Why, in a paced patient? Is that why I can't get off the dopamine? What's gonna help her...well if we do levo, we completely nullify the surgery that she came in here for...

Round and round.

I love this. I really do.


But reason #1 might be the reason ICU is Intensive Care. We have a different definition of intense here. It's not better or worse than similar nursing areas....and this kind suits me. I'm glad they love the 'turn and burn' in the ER, I'm glad they have the extremely sedated almost-dead patients that they 'put down' and revive in the OR, and that's not even the people that do oncology, or scarier...pediatric oncology. Intense in different ways.

We have 36 hours left to get her off that vent. It's a proFOUNDly complex puzzle for the team of people working with her to disentangle.

And it means life or death for Margaret. I'm sitting in her room, surrounded by pictures of her family, her pooch. They're waiting on us to be smart enough to get her out of this.

Thirty-six hours.

Sinus arrhythmia with multifocal atrial tach.

...was the most fun I had tonight. I took a copy of the rhythm strip because it's not one I'm likely to come across again that soon. Biphasic P waves. Not Q waves, mind you, biphasic P's. Definitely polymorphic, but with a regular PR interval.

Cool.

Yeah, that was the highlight of my night.

...I'm really not anti-alcohol. A few people interpreted that from my post last week and probably it sounds that way. I'm a big fan of alcohol. I may have some when I get home today.

I have another FDGB (Fall Down Go Boom) tonight. Drunk, fell down in his own bathroom, broke a bone, 911, went into DT's on the floor, then brady'd down which bought him a free bed in the ICU. Whole nine yards....chest compressions/Atropine/intubation/sedation/blah blah.

He's got a pulse and he breathes sans mechanical assistance now. He's still here cos he's crazy as a june bug. They "don't know why"...in other words, we've taken our FDGB frequent flyer through CT scans, MRIs, expensive lab test for NH4+, etc etc etc.

He's in 4 point restraints and he STILL manages to rip off his sheet and show his glorious nakedness to me every time I walk in the room. "Dude! I do NOT need to see your junk!" I just went in there to throw a sheet over him again cos he's masturbating, in spite of the foley catheter.

There's just no tellin them that it doesn't work with a foley. It's his eighth admission since November. I'm sure somebody else has mentioned that to him.

Whatever.

You should see these P waves, though. It's really cool. Highlight of my night. It's really neat.