Sinus arrhythmia

Bob Brown in ICU 17

2010-01-22T20:00:00.000-08:00

I went to dialyze patient Brown in ICU 17 this afternoon. Dr. R had told me to maximize the fluid off of the patient, but cut the treatment to three hours, because his fluid overload was so severe, and his phosphorous was so very low. I’d called the ICU, and told the patient’s nurse, Nick, when to expect me. From Nick, I learned that the patient was male, had come in with pneumonia and had alcohol-related cirrhosis and subsequent liver failure.

It’s a common clinical picture, actually. Have seen it 100 times.

I checked in with Nickfirst. He’s a grizzly bear of a man, and from what little I’ve seen of him, a damned good nurse. He gives me the lowdown of the patient’s clinical situation as well as the social story (i.e. family dynamics) in 20 seconds or less, and I always appreciate that.

I wasn’t sure that Bob was male when I saw him at first, as his face was discolored with bruises. This isn’t because anyone had hit him; this is because his liver was no longer making clotting factors. The bruising went down his left arm, and onto his left leg, too. I wonder if he’d fallen at one point. He looked every bit end stage liver failure, with a profoundly round (firm) and distended abdomen, yellow cast to his skin, and very thin, thin arms and legs from the long malnutrition of alcoholism. He was intubated, but not yet on “pressors”, or vasoactive iv drugs. His A-line showed his pressure hovering at a wan 90 systolic, with a sinus pulse in the one-teens. Intravascularly dry, severely edematous in the tissues. And bleeding anywhere a blood cell could leak. I could smell it in the air.

I was there because he hadn’t urinated in a week (shock kidney from the liver failure, and possibly hypotension). I introduced myself to Bob, told him who I was..(eyes opened, but icteric and unfocused)...and as I touched his arm, by way of introduction and reassurance, I gently pressed a finger against his skin. My finger made an indent a half an inch deep. Imagine a half inch right now….that’s deep. It told me most of what I needed to know about the shape his body was in. There was no way in hell I was going to meet Dr. R’s hoped-for goal.

Then I turned my attention to his wife, Carol. I introduced myself, told her what I’d be doing, and what to expect. I told her it was important for us to remove some of the excess fluid in his body, because it was filling up his lungs, and making it impossible for him to breathe on his own. Get the fluid out, and hopefully get the tube out. “Yes, this is our third time with this dialysis. I understand.” I smiled. She’s an old pro, then...or more likely, trying very hard to be a pro because her world is spinning out of control. I shook her hand, and told her I’d set up. She wasn’t chatty as I did so, which was okay with me. She quietly did Sudoku, and gave noncommittal monosyllables as I commented on the weather, and the depth of the snow in the mountains. I let her be, and began my spin.

I started off with a blood prime, meaning that I pull almost a unit of blood (most adult bodies have 5 to 6) out of the body before returning any saline to compensate for the volume loss. I do this whenever I think I am at risk of having to give more fluid to a patient than take it off, which is ultimately harmful to the patient. Most patients roll with this all right. His pressure dropped 20 points. His body didn't like it. It took him 10 minutes to recover.

Nick came in to check, as the alarms went off at the desk. “Need anything?” “Nope, sorry, I blood primed him. He’s a closed circuit now, and I’m hoping it’ll go back up.” He nods, repositions the patient with me, gives a few meds due to the patient, reviews some orders with me.

We’re busy, and we’re also noticing that the pressure is crap, and we’re busy so that Carol is less aware of the fact that Bob’s pressure is crap. Oh, says, Nick, “incidentally”, I got a PICC line placed today, in case we need it. I nod. This means: “Let me know when you want the Levophed. I was prepared for you.” I coulda kissed him. This is wonderful. He knows we need it; he's known for three days that he's taken care of Bob. He knows. We don't diagnose. But we do know, and we prepare for it.

The pressure recovers somewhat. But I'm aggressively pulling fluid out (i.e. pulling water from the pipes), and I fight with Bob’s blood pressure for an hour, having to give back almost every milliliter I’d gained. After an hour, I’d gotten a half a liter. This is pathetic, compared to the goal set by my doc. My doc's goal was to help get him off the ventilator, and that wasn't going to happen with a half a liter an hour.

Bob’s sister arrived at the bedside, and was asking questions. Carol was too weary to notice how often the pressure was too low; Bob’s sister was not. After a full hour of the treatment, I paged Dr. R, to let him know that we were getting nowhere. He asked me to try albumin. Okay, cool. Let’s try some albumin. Nick gets it from the pharmacist for me, as I explain to Carol and the sister what albumin is, and why we think it might help.

Alcoholics have no albumin to speak of. This is because they do not tend to eat. They drink instead. I explain this gently, by saying, “Bob probably had a very poor diet before, (Carol nods) and that, compounded by the fact that his liver isn’t working, is making the amount of protein in his blood very low.” And then I explained that it would effect the amount of fluid I’d be able to take off…big molecules and little molecules. The sister appreciated the explanation “in English” (as she said), but Carol was in sleep-deprived numbness. She nodded when her sister-in-law nodded, and let someone else ask all the questions.

The sister asks about how the machine works, and I tell her. Dialysis is easy...it's salts and water. People can understand saltwater. And it works with the heart, which is also easy, because that's just electricity and plumbing. I mean, obviously, an electrophysiologist disagrees, and s/he is right....cardiac automaticity and periodicity is ridiculously complicated. If you're interested in those groovy details. I love pathophys...and I to love the complex chemistry behind dialysis. Bob's sister doesn't care. But she gets it when I tell her I'm squeezin out saltwater. And that I have a filter (to which I point) and this is where the blood is cleaned before I pump it back into her brother. And she appreciates understanding.

Before I finished getting the albumin into Bob, his pressure dropped to 69/32. Nick was at the bedside with me (because it looked dicey well before that), and I said, “Nick? Do you have an intensivist handy?” “Yup, whatchoo want?” “Um. I just suspect it might be a good plan to tell him we’re havin trouble getting fluid off.” “Yup, me too.” Exit Nick, for a few minutes.

I explained to the two women that the physician might want to consider a medication to keep up Bob’s pressure, since it just wasn’t cooperating. Because they wanted to know what to DO, if the fluid won't come off. I said the medication was ‘a big gun’, but that it might help him. It was serious, but it was just a tool, like everything else. The sister-in-law loitered some, but left, because Carol told her that "Bob is supposed to rest today."

Nick brought in a line already primed with Levophed. (Did I mention that this guy is an awesome nurse?) As he hung it, he explained what he was doing to Carol, too. She nodded. Repetition isn’t done to annoy when your family is in this state; it’s because they don’t really hear what you’re saying. Nick did warn her that the good thing about it is we’d be able to get fluid off. The downside is that there was a risk that it would be difficult to then wean Bob off the high-octane medication. She nodded again. And went back to Sudoko. Or numbers on a page.

The good news (sort of) is that I was, from there on out, able to pull fluid! (I guess this was a win, right?)....

Carol and I sat mostly quietly for another hour. She had her Sudoku, I had an eggplant-colored ball of yarn I was crocheting into an afghan. Sometimes she would call someone, and talk about Bob, and this "blood pressure medication...he's on the dialysis now...he's still on that breathing machine...he doesn't look good today....I wonder if he's in pain, because he looks so uncomfortable right now...." Interspersed with more quiet number puzzles and crochet loops.

The intensivist came in to see Carol. I was a little fly, stuck to the wall, in a small chair in the corner. A dialysis nurse isn’t supposed to go far when s/he is dialyzing, and I tend to sit quietly in a corner and read. Today, I made eggplant-colored loops, 150 to a row. I am stuck in the corner as this happens:

Doc was gracious, and kind. He was also truthful, which is my favorite kind of doc. He told her that the prognosis was very poor. He said, “He has several organs that aren’t working right now, we say they have ‘failed’. His kidneys have not made urine in a week, his blood pressure is too low, he’s unable to breathe on his own, and his liver has severe damage from cirrhosis. We can put him on the ventilator to support his lungs. We now have him on medication to support his heart. We are doing the dialysis for the kidneys. But the liver…. Transplant is not an option with a history of alcohol abuse, and transplant is the only thing we know how to do for the liver. We cannot do anything about his liver. He is in very serious condition, and we are not seeing improvement. We are seeing a gradual decline. I feel his prognosis is very poor at this time.”

Carol was standing, and nodding. She was hearing, and part of her was understanding. “I understand.” She was calm (sort of) but, “Nobody had told me yet that this was ‘end-stage’” She nodded. Shuffled her feet.

In short, no doc had actually said yet that Bob was going to die. She suspected. She said she’s talked about it with her family, what they would do, what Bob really wants. But nobody’d SAID it to her yet. She was waiting, fearing, to hear it. And now she’d heard it.

And this is why I have profound respect for intensivists. Because every one I have known has had to deliver this news to someone who deeply loves their patient, this person lying in the bed. And because intensivists are THERE at the ICU bedside, they see this suffering, and they understand that when it is time…it is so important for them to be honest and say that it is time. And the intensivists I've worked with have been honest and I think that takes courage.

The doc said, “I’m very sorry to have to deliver such bad news.” She nodded. She said Bob never wanted this much STUFF (gesturing to the entire room). This is not how he wants to live; they have a living will that is very clear. “He doesn’t want all this,” said Carol, “I’ve talked to the whole family and we all agree that if he isn’t going to get better, he doesn’t want this.” She wobbled. He pretended not to notice. I made eggplant loops and tried not to breathe loudly in the corner.

The doc said gently, “What we can do, then, is maybe wait a day or two to see if we see any improvement. To be honest, I do not expect any, but no doctor can tell you for sure what will happen. If he does not want us to do this, we can stop this. Why don’t we give it a day or two and then make that decision?” “Okay…..How long?” “Maybe we could re-evaluate, say, Sunday? Will you be here Sunday?” “I will be here Sunday…..I will be with him. I will be here. Yes. I can. I can bring the family Sunday, too. Yes." She nods more.

The doc nods, too. “I am sorry to deliver such bad news.” She thanks him. Nods. He nods. He makes a quiet exit. She turns to the window, which is dark because it is evening. I can see her reflection in it quite clearly. She holds her hands over her face, with her index fingers in the corners of her eyes. She is very still. I think I hear the word, “Sunday,” a whisper.

I stand up and walk softly, in my rubber-soled shoes, up to Carol. I touch her left shoulder, so as not to startle her. And then I wrap my arms around her shoulders and put my ear to her shoulder and squeeze.

She shivers, and then a sound comes out, a little like an infant’s burp. And then there’s the sob…...this...SOB, this reverse gulp of air....less a sound than a shockwave from a mushroom cloud. Before it becomes red or grey, when it's just this visual disruption thing. Not heard, so much as felt , down in the belly, right in the gut...and it feels like it has hit every bystander within 10 miles and made them wobble and gasp for air.

My eyes sting with saltwater and I hang on tight so that her molecules do not fly apart.

My buddy "Zack"...

2009-10-05T18:42:00.000-07:00

...who I wrote about on August 31 is sitting 20 feet from me, dialyzing 'emergently' again. His blood pressures are in the 220s over 130s. Heart rate in the 120s. Potassium is 6.7. Creatinine of 10.1, and BUN of 28.

He left hospital Q on Saturday, against medical advice. Now, he came to this ER and I drew the short straw.

"Zack," I said, with large 15 gauge needle in my hand, "I'm not trying to piss you off or anything here, but seriously, why do you do this to yourself?"

"Do what?"

"Blow off your dialysis appointments, the dialysis that is keeping you alive, and drag your butt into ERs around town when it gets too bad?"

"I'm supposed to go tomorrow."

"Yes, but why didn't you go to the one you were supposed to go to in the beginning? The point is what brought you HERE...TODAY... And every other time we see you?"

"I don't know what you're talking about."

At this point, I jab the first needle into his skin. This is soothing. "I think you do, because I don't think you're an idiot though you are acting like one."

"No I don't!"

"Whatever. Sit back, relax, and I'm not taking you off this machine for four hours even if aliens land, so don't even think about it."

I jab the second needle into his fistula and hook him up. I let his admitting nurse know he's here, what's goin on, brief history, and to be mindful of where her Against Medical Advice paperwork is. She may need it.

Thank you, Colorado taxpayers, for paying for my services today. I'm a nurse and I save lives.

....

(Maybe I'll have some nice, responsible patients who want to get well later this week. One can hope. It does happen sometimes.)

Americans and their sliced cheese.

2009-09-22T10:47:00.000-07:00

I stopped off at the grocery store after work Saturday, still, of course, in my scrubs that mark me as a Healthcare Person.

I was in the dairy section as a large man using a walker huffed and puffed and sweated past me. He burst out in frustation (to me): "WHERE is the sliced cheese?!?" (Since I'm a nurse, of course, I know everything and am trustworthier than other customers.)

I pointed to a location across the store, and said, "Oh, that's way back near the meat stuff on the other side of produce." He shook his head, agitated.

I said, not unkindly, "Or, save yourself a few cents and slice your own cheese. The blocks are right over there." (Pointing to a refrigerator around the corner from us.)

"I have arthritis! I can't cut cheese myself! I can barely walk!"

I bit my tongue out of habit, because I'm polite by habit. I let him stomp and huff his walker away toward the sliced cheese section. Infantile cheese-cutting jokes aside, what I should have said is:

Well, if you cut your own damn cheese and USED your muscles in your hand, you might not lose use of your hands completely.

Or:

Better yet, skip the damn cheese altogether, lose 125 pounds and watch your arthritis diminish to a tolerable level, you whiny, lazy bastard.

I should have. I really should have.

I wear scrubs, and I know what I'm talking about. I'm trustworthy, even doing my grocery shopping. Right?

How do we do this?

2009-08-29T08:59:00.000-07:00

Steve commented on my last post, suggesting that there are two sides of reform needed to fix health care. The users and the payers. He's right.

Insurance has an important place in the picture. We could have a system that each individual pays out of pocket for all their health care needs. This works for the very healthy and the very lucky. I myself was minding my own business one day in January of many years ago, standing at a streetlight, waiting to cross...and a Pontiac hit a patch of ice, popped up the kerb and took me with it. I don't remember the car accident (which was a hit and run). The first thing I remember after the 'minding-my-own-business' part is waking up while being rolled into an MRI.

In 1994, that entire mess had cost upwards of $25,000. Which is cheap by standards I know now. But when I was 25 years old, I was living hand to mouth and that 25K might as well have been $25 million. I was glad of having insurance. I was lucky. Dumb, stupid luck.

Thousands of people are not lucky, and bad things happen to good people all the time. Insurance holds a very useful place in the economy. It's a gambling business....who to whom can we provide a safety net while keeping the most in our coffers? There is absolutely nothing wrong with this. Yay, capitalism.

Logically, though, this leads to abuses. It's expensive to treat human beings who've been unlucky. With cancer, tuberculosis, diabetes...you name it. Obama's discussion does focus on reform on the insurance end of things.

So what DO we do about the other side of the equation?

I am not a doctor, and therefore, do not know boo about medical malpractice. I believe the many docs who say there needs to be reform here. My guys say it all the time. Others can speak to that.

What do we do about the fact that among users of health care, some people abuse the system? Read any nurse blog out there, and you'll find stories of those patients we really don't enjoy taking care of. How do you make Americans responsible, accountable, fair users of the health care system?

What if every American was required to carry health insurance, the way that you must have car insurance to drive a car....irrespective of pre-existing conditions. Obama's plan could conceivably force this in a number of ways.

Would spending less money out of pocket motivate people to improve their health? Might there be incentives in discounts on monthly rates, or in deductibles or in percentage paid for services? Incentives for:

* Having a healthy BMI or weight range or body measurements range?

* For belonging to a health club? For fitness training? For working with a physical and/or occupational therapist for some post-op surgeries?

* For safe driving records (e.g. no DUIs)?

* For proof of appropriate annual checkups that make sense? Annual physicals, or well-baby, or gyne PAPs/breast exams for women over 18, eye exams for those who need it and for people over a certain age (40? 60? I don't know). Mammograms for women, prostate exams for men...etc.

* Among diabetics, incentives for having good quarterly HB1AC values? For going to cooking classes? Among ESRD patients, incentives for going to their dialysis appointments three times a week, having good monthly KT/V and/or albumin numbers.

I don't know. I'm not sure how to encourage Americans to take care of themselves. Saying 'this is good for you' is useless. Saying 'this is less painful and difficult for you' is useless.

I'm thinking out loud, and I don't think any of these are original ideas. How else could we curtail user abuse of the health care system. Quit giving Dilaudid to people not genuinely screaming in the ERs?

I beg my docs to not order 'stat dialysis' after hours for patients who blow their dialysis appointments the same day, come into the ER feeling crappy, but their potassium levels are not yet dangerously high. I ask if they can wait 12 hours until morning. Some of my guys do this, some do not. It's a cost difference of a couple thousand dollars to the hospital/Medicare/the taxpayer. Rarely has this 'stat dialysis' been for a patient who missed an appointment in good faith. It's usually people like Zack (see below). (Zack, by the way, has been back to Hospital B this week.)

What else can we do to prevent abuses by the users of health care?

A tale of two patients.

2009-08-21T19:39:00.000-07:00

Meet Zack. Zack is 26, and will be dead by age 30. He has severe hypertension (240s systolic tyically, because he will not take medications to control his blood pressure). His kidneys have been blown out for a few years due to that bustin pressure, and he has an appointment slot at a clinic.

He doesn't go.

Last month, he was in Hospital A's ER "because he felt like ****." We dialyzed him, and he left AMA (against medical advice). He did not go to his scheduled dialysis appointments. Four days later, he returned to Hospital A's ER "feeling like ****." I dialyzed him, we discharged.

Last week, I saw him being dialyzed at Hospital B by one of my colleagues. I didn't ask why or when or whether he ended up again, leaving AMA.

Today, he was being dialyzed by a different colleague at Hospital C. He walked unaided to the inpatient dialysis room. This delightful boy flopped on the chair and barked at my colleage, "I'm having some ******ing pain, I need some ****ing Dilaudid. Those pills never work. It's chest pain. Eight out of ten." By the time we did our end-of-day hospital charges, his name was greyed out as being 'discharged'.

Now....call me stupid, but if you're going to different hospitals and sleeping over at least twice a week, going to your thrice weekly outpatient appointments seems like less bother. So is it about the ******ing Dilaudid that makes you want to spend the night at different hotels around town? If it's really that great, why not stay in the hospital and keep getting more?

I don't know for a fact that Zack doesn't pay for hospital bills, which cannot be less than $10,000 each visit.

But I do know that it is being paid for somehow, by somebody. The hospitals may write it off, but they do not take a cut in profit for someone like Zack. Those costs shift to elevated costs on other patients.

The next time I see Zack, I may ask him if he pays his multiple hosptial bills. I will be standing out of arm's length (he's thrown a punch at one of my colleagues, who is 60something and a grandmother and sweet as pie).

But I'll bet you're wondering the same thing, and for you, gentle reader, it might be worth the string of expletives.

****************************

Meet Josephine. She is 82. She is trim and active. Her two sons and their families live close by, and she has a strong network of friends. She went to the ER yesterday "feeling strange and nauseous" and they found Josephine to be in a rapid AFib. She was cardioverted today, and popped (tentatively) into sinus rhythm. (Cardioversion = low-end electric shock to heart in controlled environment.) (This can hurt.)

We also found her creatinine and BUN to be elevated enough that acute dialysis was appropriate. The cause of the acute kidney failure isn't yet clear.

She was profoundly exhausted when I arrived to dialyze. The fentanyl and versed had knocked her tiny, drug naive body SO hard that she got Narcan'ed and Romazicon'ed (reversal drugs...unpleasant to even watch them being administered). Fortunately, she does not remember this. She just really, really wants to sleep.

So I set up my half-ton of equipment and did my chart review and lab review and normal routine. Got her blood spinnin. I had assured her that once it was going, she'd have a nice quiet nap. If she woke up, I'd be at her bedside, charting and reading if she needed anything. Easy. That's what we did.

A few minutes into her dozing off, her eyes suddenly snapped open, "Is this? (she points to me and to my machines) Is this paid for by my Medicare?"

...."I'm sorry??"

"Because I have Medicare and supplemental insurance through ABC Company." She was genuinely worried.

....

Here's a LOL (little old lady) who just had 50 or so Joules direct to her heart, a cocktail of narcotic and anxiolytic that tied up her brain's opioid and other happy receptors so completely, her respiratory drive started to crap out...and then they administered meds to rip all those happy molecules right off her brain (ouch!)...and then I come in, slurp her blood into a machine, whip it around, pul off more electrically charged molecules, dumpin protein into her body to keep the blood pressure stable...and...

And she couldn't drift off to sleep because she wants to make sure she can pay for my services.

...

....

Ejection fraction of 4

2009-05-02T22:26:00.000-07:00

F O U R

Patient walked into the ER, and within an hour, fell down, went boom, and landed himself in the ICU with FIVE maxed-out pressors, cooling blanket, CVVHD....everything but a head bolt.

Think about that: ejection fraction of F O U R.

When his heart beats, it spurts out 4% of the blood volume that sits in his heart while it is at rest. How many cc's you suppose that is? If his heart has 100cc at rest (possible, but probably more), it would pump out 4cc at systole.

I can spit more than that.

Jeez, if I'm sleepin good, I can DROOL more than that.

And what does it mean to max out dobutamine and dopamine on a heart with an EF of FOUR? Dobutamine, dopamine, levophed, epinephrine and vasopressin.

The frustrating thing to me is that I don't get to find out what the hell happened to this guy (other than the obvious cardiogenic shock...*why* the cardiogenic shock, I won't know.)

EF of 4. New record for my personal little observations.

The conscience clause.

2009-04-21T23:00:00.000-07:00

This may be one of my last posts to Sinus. But I’d like to get involved in one more nurseblog debate on the conscience clause and the discussion as to whether Obama should work to undo this legislation.

Namely, Emergiblog Kim’s initial post here

And subsequent ‘rebuttals’ (if you will):

Duncan Cross wrote.
And Manchmedic wrote.

I agree with Manchmedic.

I think that the government has no place regulating …as part of a state Constitution (much less Federal)…what private American worker should do as part of their job description for a private employer. Legal precedent exists to protect workplace safety (OSHA, child labor, harassment). The government can direct a soldier to war, because that soldier enlisted for that job description. (I don’t like the draft, either.) There are laws about taxation on income, and discrimination.

But this conscience clause is about driving contractual details (i.e. job description and responsibiities) between private corporations (i.e. non-VA hospitals) who hire citizens as employees.

Despite the fact that all civilized people believe that workplaces should be equal opportunity, the need for actual LAWS within a state or federal constitution that direct how workplace equality is to take place is still debated.

California nurse to patient ratio laws are new. Some CA nurses have said that their ratios are better, and they've lost ancillary staff and charge roles as hospitals even out the bottom line. That the ER's overflow. Government with good intent is slower than private enterprise. Perhaps not the optimal solution.

In my opinion, Dubya confused church and state and understood neither. Our founding fathers were very clear on this whole church-state separation thing. This issue is not about God, or beliefs, or hot-button Roe v. Wade.

It’s about what your employer expects that you do for them.

Do you really want the state constitution getting involved in that?

On this ground, I think the clause is a horrible idea and should be un-done.

****

There’s a secondary reason why I disagree with the conscience clause.

I believe with every molecule comprising my body that every human being should be treated that way when they leave. That they should be treated in a way that THEY direct. That we should do the utmost to provide for THEIR needs. That they are free of pain. That they are treated with dignity and respect. That we do everything we can to alleviate the other horrible undignified ‘symptoms’ of the dying process: nausea, vomiting, incontinence, wakeful coughing, clinical anxiety. And in the best situations, people are surrounded by love. The reality is that not everybody’s gonna get that. But I believe it’s what we need to aim for.

Some nurses like sunrises. I like sunsets.

Babies are great, fun, joyful. When I am the best nurse I'm capable of being, it's often with a patient who has made a decision that they're ready for their next big adventure. I am a rabid advocate for pain and symptom management.

I don’t believe in flogging bodies through endless complex procedures that have poor chances for positive outcomes. But sometimes I do it. I'm dialysis, for chrissakes.

There are many situations where I have participated in medical care that violates my humanist beliefs in the right for a patient's dignity and self-direction. Every ICU nurse has participated in cases that have gone before ethics boards. The young person who is HIV+ and after long, protracted illness, wishes to die. A parent wants everything done. Ethics board decides to go for the gusto. Dialyze!

A patient whose family has such financial interest in keeping patient alive that they are able to get him declared mentally incompetent under suspicious circumstances. When clinical psychiatrist, after thorough evaluation of patient, finds patient (to no surprise from staff) to be not only sound, but erudite and thoughtful about his own care, lawsuit by family ensues.

The dialysis patient who is a social work nightmare who becomes pregnant…the highest risk pregnancy I have ever seen. Patient has multiple hospital readmissions since the birth. Have we done that child any favors? Will the child become president or did we bring a human being into terrible suffering and adversity?

I find it morally reprehensible to paralyze a patient with vecuronium and provide no pain medication. I have done so and charted the hell out of the calls to the cardiovascular (bastard) surgeon who had me perform this odious torture. I advocated for my patient in much gentler ways through the family (uneducated in such medications) as well.

I have NOT given blood to a Jehovah’s Witness with a hemoglobin of 5, because the patient does not want that intervention. The patient understood that a lot of physical suffering could be alleviated. To the patient, the spiritual suffering would have been worse.

At no point in time did it ever occur to me to refuse to care for any of these patients. My point here isn’t that any good nurse would not have provided the same care. My point is that a pro-lifer's moral difficulties with abortion are very like my moral difficulties with the 92 year old CABGx5.

But here’s the rub:

IT’S NOT ABOUT ME.

If I don’t want to do the job, I can find a different job. There are nursing jobs that will not put me into a situation that violates my humanist values. My chosen nursing path so far is one of the least morally obstacle free I could have chosen for myself: critical care and dialysis.

However, if I am not going to choose to get a different job where I find such tasks ‘morally repugnant’, I choose to be a professional. You do your job. You prolong the life, you give the person comfort AND advanced intervention of Western medicine. Chemo. Or dialysis. Or intubation. Or surgery. Whatever.

It is not for me to decide whether or not a woman should have an abortion, or a 92 year old should undergo a cardiac bypass graft times five. It’s not for me to decide a crack addict has any business going home with her premature baby. It’s not for me to refuse to take care of an critically ill withdrawing alcoholic/any-other-substance-abuser because I think alcoholism/substance is ‘bad’. Or whatever.

I volunteered at a health fair today and a man asked me which substance be more 'okay' for his heart condition: cocaine, marijuana, alcohol or speed? I answered his question indirectly: cocaine and speed will kill you. No, I don't want him to go smokin pot.

It is for me to provide the best clinical and compassionate care for the patient that I can. I’m not giving up my personal rights as a nurse. Nobody’s asking me to have open heart surgery. Or do anything with my body. Or take up heroin. If I find somebody else’s medical choices to be repugnant, that is entirely my problem.

Besides.

Nobody LIKES abortion. Think about it. Whether you’re pro-life or pro-choice, nobody thinks abortion sounds like a fun time, or something that’s really cool. Nobody says, “Hey! Let’s murder a fetus/baby (whichever you prefer) today!” No. Nobody wants to have one. Nobody wants their daughter to have one. We are all in agreement on this point.

The great thing is that we don’t have to agree on whether abortion should be available to women or not. Abortion is available to women by law and has been since Steely Dan was cool and I was still in diapers. In 2003, one method of abortion was made illegal, thanks to Dubya. Nobody is asking any of you nurses to ‘participate’ in that procedure, as no one is performing it in this country.

****

I don't need a clause in the constitution of my state to tell me that I can refuse to participate in a medical procedure.

If I have a problem doing my job, I can refresh my resume.

Compassion...

2009-02-27T15:10:00.000-08:00

Found out today that I'd pissed off a patient and he managed to complain to my boss. Was yet another chronic, obese, bastard who didn't feel like going to his dialysis appointment one day. So a day later, c.o.b. goes into the ER of Suburban Luxury Resort That Has A Starbucks But No Water Hookups And Bills Medicare with chest pain.

I actually do understand that a life shackled to a dialysis clinic is a hard life. But the choice is to go or land in the hospital. I don't doubt that this is a painful thing. You will not garner sympathy by acting surprised at this turn of events, however.

I asked him, "Why didn't you go to dialysis on Wednesday?" He sniffs, "I wasn't feeling well." "Well, um, you're in the hospital now, how do you feel?" "Lousy." "I'm sorry you feel lousy. Why didn't you go to the ER yesterday?" "BECAUSE. I. WENT. TODAY."

Big fat duh. He's one of our frequent-flyers. He knows damn well how to work the system. He lives closer to one of the less luxurious hospitals, but he drives a half hour to the ER of Suburban Luxury blahblah because he knows they'll admit him. He finds me rude because I'm supposed to meekly treat him and not call him on the fact that he's milking Medicare for all its worth.

I was dialyzing the bastard at 10 o'clock at night while he was in his hardwood floor-ed single room watchin the flatscreen tv. He's got a free hotel room with predominantly twentysomething cute RNs to wipe his ass for him and a fresh cup of Starbucks every morning in his private room. He didn't like me and loudly told me so in those words. I said I was sorry to hear that, but my affect showed clearly I didn't care. I put his fistula needles in and I didn't do it gently. So he complained about me.

My boss asked what happened, heard the story, and then shrugged. "These patients are often ....difficult." Proceeded to tell me her favorite asshole patient story. "We just have to be mindful of our bad days, too." I nodded. Yeah, I know. C is a nurse too, and not a saint. We have "bad" days when we tell irresponsible people that they're irresponsible.

Which leads me to Head Nurse's blog about compassion. Head Nurse (also a Jo) was picked at for "not having compassion." She's defending a nurse's right to blog snarky.

The other day I dialyzed a Vietnam vet, who took high doses of daily methadone, smoker, chronic pain. He sounded like he had Tourette's, but I'm sure that wasn't a formal diagnosis. Everything f*ck this, d@mn that, sh!t this and that. I stretched his legs for a half hour. They were as tight as lawnmower belts. Slow, gentle plantar- and dorsi-flexion. It helped him. I just felt like doing it. Think I'm an angel and he's this poor, sad, sick man? When I was done with his legs, he told me his ass was hurting him. I just looked at him as if he knew better than that...and he did. "Sorry, I don't do ass massage." Sheepish, he nodded. "Well, thanks, that helped my calves a lot." "You're welcome."

I told my bf the first part of the story and he thought that was really "sweet of me" and "nice of me to do that". I told him the second part of the story and didn't know what to say at first. Because in the real world, I don't do nice, selfless acts for poor, suffering people. Or at least, it doesn't work that way most of the time.

The general public doesn't know what to do with nurses. There's is a greater stereotyping for nurses than there is for MDs. People expect docs to tell them what they want to hear, and to have Dr. Marcus Welby bedside manner, to be right all the time....but they also expect that docs be compensated well for this. Nurses are either dumb doctor-secretaries or saints/angels.

I'm none of those things. I have my own scope of practice that is collaborative with that of medical doctors. You don't want me diagnosing your weird condition, but you also don't want the majority of (non-surgical) MDs coming anywhere near you with needles or catheters. I don't do things to be saintly or angelic. I get paid to help treat patients to improve their health, to educate patients on their health/illness/diet/medications and to alleviate pain and suffering.

Yes. I get paid to do those things. I could get paid to do other things. But I choose to be a nurse.

If you're a patient and you're a dickhead to me, your expectation that I smile and sweetly take it is erroneous. I can stick really big f*cking needles into your fistula and I don't have to do it gently. If you're that stupid to verbally abuse a nurse that you KNOW has to put two 15 gauge needles into your arm, well...maybe you'll learn for next time. I can tell you bluntly what will happen to your body if you ignore medical advice. Take a swing at me and punch a pregnant nurse in the stomach and expect me to tie you down in leathers and I'll make it tight. Try to choke me, and I will put my hand around your throat until you let my throat go. Call me every name in the book and expect that pain medicine you want to not be my top priority.

I get paid to treat you. I don't get paid to be verbally or physically abused by you.

Why is that difficult for the general public, and for my patients?

I don't tend to blog about the gentle things I do. Thank you cards I've received from patients. Hugs and hand-holding. Times I've gone toe to toe with a doc on behalf of a patient. Can't even tell you the number of times I've shamed surgeons into giving pain medicine (aPALLing the number of times that's been necessary). Times I've helped to successfully treat patients, when my care over a shift has clinically improved the patient's outcome. When I've identified problems before the problem gets worse. All the preventative care I do, all the times I feel like a patient or a family member has come away understanding a disease process or medications or whatever because of the time I took to talk with them.

I don't do that cos I'm normal and I get paid to do a job, and like everyone else on in America, I gripe about what bugs me about my job.

I don't know else what we nurses need to do to fix these stupid perceptions. But we need to do somethin.

What I wish patients would do:

2009-02-27T10:57:00.000-08:00

Lose 100 lbs. (The many that can afford to lose those pounds).

So Happy Hospitalist is a rabid anti-smoker and he lectures his patients on their smoking habits. That's good. I applaud that. Smoking gets under his skin, and it pisses him off that Medicare covers the serial intubations of smokers who continue to smoke. That pisses me off too.

What pisses me off is morbid obesity. Like smoking, morbid obesity is a choice. No, nobody did hold a funnel to your orifice. The argument that you don't have the emotional control means only that you need to be responsible and OBTAIN self-control. If you have an eating disorder, seek therapy, not my sympathy.

A full 37% of the American population is obese. Not 'overweight', not 'wish that damn 7 lbs would go away'....no....rolls of fat obese. Can't get oxygen into their bodies while sleeping because of obesity-induced sleep apnea.

I was at a hospital yesterday dialyzing a patient who is so obese, her bed needs to be constructed inside the room. She is unable to leave this room. There are TWO patients currently at that hospital that we dialyze this way. It's actually not uncommon anymore.

The patient barely spoke to me yesterday because she hates the whole dialysis process. She begrudgingly answered my questions and consented to do things like moving her arms so that I could get to her vascatheter. The one time she did speak to me was to complain about the bland food. "Your diet is killing you, Mrs. RollsOfAdipose." "You think I should eat that food?" "I think you are in the hospital because of your weight. You are unable to leave this room because you're eating yourself to death. You need to change your lifestyle or you will die here. A few vegetables might be what you have to do to get out of where you put yourself." She was mortified. And was infuriated at the suggestion that soon, she would need to actually leave the room to go down the hall to dialyze. "I can't sit in a chair for 4 hours."

The old....I'm so fat I can't sit up excuse.

In the meantime, I haul a half ton worth of machinery to her so that we can get all the damn potassium and protein wastes out of her blood so she doesn't die.

One nurse I respect told me a story that she was bathing an obese woman one time, and found a Twinkie in the woman's rolls. The woman giggled and told this nurse it was part of a game she and her husband play: find the food.

I don't actually make this stuff up.

If you're over 30 BMI (and you are neither very pregnant nor a bodybuilder), you need to stop the madness. Unless you're Mother Teresa or Albert Schweitzer, you don't deserve dessert every day. You need to eat some vegetables instead of Big Macs. You need to cut your portion sizes down by two-thirds. That's not debatable, much as you'd like that to be told to you in a more sugary sweet way. You're fat. You did it to yourself. You choose to stop, or you choose to die slowly, painfully in a medically protracted and undignified way. Period.

I have no sympathy for the 'helplessly' obese people that big. The vast majority don't have an eating disorder. They have Entitlementus Americanus Lazii. A lousy economy might be a partial cure for that.

I'm tired of my taxes going to paying for specialty beds to be built in your hospital room. My taxes pay for your insulin. They pay for your CPAP machines. Your weeks and weeks of inpatient hospitalizations. Your dialysis treatments, your heart surgeries. Worst investment my taxes ever made.

Dear MD, please write some orders for me. Thanks, your friendly RN

2009-01-30T17:13:00.000-08:00

(Here's somethin you don't hear out of nurse blogs on a regular basis.)

Dear MD,

I did not go to medical school, nor did I do residency. I am not a doctor. I'm a nurse. I know a lot about health and medicine, pathophys and pharmacology. I can predict with a good degree of accuracy what drugs, doses, diagnostics and treatments make sense for a patient.

An MD should WANT me to be able to do this. We have a human-made and broken health care system and mistakes happen all the time. I am another clinician that helps protect patients by ensuring the drugs and treatments you want for our patient do what we both want them to do.

But the fact is that you have twice the amount of time, and a much more comprehensive training in the field. I don't diagnose. I don't prescribe. Yay for us both and for the patient. I have a good degree of accuracy....enough that I feel confident seeing a nurse practitioner for my general health stuff. But for my more complicated breathing stuff, I see a pulmonologist. I know the difference.

Here's my trouble: when I come to dialyze our patients, I get the name of a hospital, a last name, and sometimes a room number. I don't get any report on these individuals; I do not have the luxury of reading health and physical history, recent orders or even speaking to the patient before I get 75% of my dialysis treatment set up. I get some lab values, which allow me to predict the correct potassium prescription.

Let's go back to that sentance. I get some lab values and predict a potassium prescription (granted it's not that hard for dialysate) in a population with common comorbid cardiac issues.

What I ask of you is that you write me some orders for the treatment parameters. When I receive the chart, I often am going on orders you wrote for a dialysis treatment two weeks ago. Sometimes the patient gets two hours of a treatment I decide upon before you see them that day. Sometimes it's their first treatment and I am making those decisions until you arrive an hour or two into the treatment.

The good news is that I'm right most of the time. It is first grade math to subtract a serum potassium from seven.

The bad news is that I do not have MD behind my name and you do. Please don't leave these decisions to me. Please don't grouse when I ask you to write me some orders for the treatment I'm halfway through completing. Please don't look at me as if I'm a moron who's asking to be told what to do when it's seemingly obvious what I should do.

It protects us both. It's best for the patient. I do not have any business deciding how much potassium to give a patient, how much Epogen, how fast to dialyze a new patient who's never had dialysis before. I know that. I also know you're busy and have 35 patients to see today. I get it. I also know most of the other nurses on the team do this all the time. But I think they allow this to continue because they interpret this possible laziness/busy-ness on your part to be a vote of confidence in them.

It doesn't take much to subtract from seven, yes. But what you may not know is that other physicians are altering other electrolytes through the treatment that are providing benefit to the patient. They're giving additional drugs that may be beneficial. They're even having me change the direction of my dialysate flow (something I need to know 35 minutes beFORE patient arrival), to reduce the risk of adverse outcomes on new patients.

That's not first grade stuff. And for treatments I 'prescribe', I don't do that. But maybe you should. Or maybe it goes through your head to consider, but you never get around to writing it down, so it never happens.

I respect what you know. This laziness is possibly a nod of confidence to me, or maybe you think any monkey can do what I do. Either way, I don't care. It isn't right and there are clear legal scope of practice boundaries, no matter how busy we are. These boundaries are for the best of the patient.

So just. Please, write me some orders.
Thanks
/jo

Clinical case study du jour.

2009-01-15T23:16:00.000-08:00

So I got a call at 17:00ish today to go to the Hilton Hospital of Suburban Growth Upon My City (you know, the one with the Starbucks). All I get is: "Go to HH of SGUMC, ICU bed 42, patient's name is Fritz and he just left a week ago. His K+ is 8."

(I was gonna name the patient something like Schwarzenpfluger but I decided that's too many letters to type repeatedly. I picked 'Fritz' instead, because it's a nice name and makes me think of nice schnauzers I have known.) (Why I'd think of schnauzers I don't know. It's been a longass day.) (Note: Patient is not of German heritage...Germany is just on the brain this week.)

So my first thought is that Fritz went home and then didn't go to his dialysis appointments, and then someone found him dead, called 911 and there you have it.

Patient is early-mid40s, alert, chatty, polite. He doesn't look like an end stage renal patient at all. He doesn't even look like he was dead a few hours ago. No apparent neurological residual...he's freakin texting somebody on his cell when you get in. (Can you imagine that text: Dude! Died today. Came back. Txt me when you get this.) ....but definitely not a chronic kidney....his skin is healthy, for one. He's not depressed, for two. Third, he's not watching either Jerry Springer or the Food Network, and I'm pretty sure that having kidney disease compels you to do one of those things.

"Hi Fritz, I'm JustCallMeJo and I'm here to dialyze you."

"Nice to meet you."

*boggle* Really? Did I get the right room? I address him by name to double-check. I set up my machines; I get Fritz's story.

(Also notice that the patient is on a nasal cannula only, so of course <_5L of O2, rhythm in a grossly normal-appearing sinus tach, satting well for altitude, with a normotensive blood pressure. Other assessment findings: c/o 6/10 pain, pericardial rub, pulses all palp and regular, wheezes post left lower lobe, bowel sounds hypoactive, 1+ edema BLE, two fentanyl patches on back of scapulae, permcath to R IJ and a #18 rather ugly field IV in the L AC, unmessy #20 R hand IV.)

Turns out he has mediastinal cancer, which I would not wish upon Pol Pot. It's horrible, cruel and unusual. It metastasized to a kidney. To complicate things, his first round of high octane chemo caused acute tubular necrosis (as chemo sometimes does.) Acute kidney disease became chronic kidney disease, and he became dependent upon dialysis.

This all sucks in ways profound and deep. But this guy decides to choose life when life has handed him lemons laced with battery acid and prune juice. Amazingly, he's on board. He has GONE to his dialysis appointments as scheduled. He and his wife are asking me good questions about the renal diet, which IS genuinely confusing and difficult. One of his parents is present, and the parent asks me really detailed questions about kidney physiology and how the dialysis machine works. ("So, what are the filter fibers made of?") (What ARE the fibers made of? I have never been asked that.) (I'm explaining finer points of ultrafiltration, diffusion, osmosis and molecule size of creatinine to people who are ASKING about it. I mean, nobody but ME likes that stuff.)

Point is, this is a guy that intends to live. This is a guy that will do whatever sucky things life is requiring him to do. This is not my usual patient at ALL.

So.

This morning, his wife finds him down, unresponsive, foaming at the mouth. She does CPR. For real. Jane Anybody calls 911, does CPR ...and this woman saved her husband's life. (I just think that's amazing.) EMTs arrive, intubate him, lights and sirens to the HH of SGUMC. Upon arrival, he codes again. They find his potassium to be 7.3. During the code, they did glucose, insulin, bicarb and calcium. No Kayexalate, no Narcan, no Romazicon. Some intensivist decides to call the nephrologist in to evaluate for stat dialysis. Meanwhile, as they're getting a nephrologist to come in urgently, who then has to see the patient, call the scheduler, who calls me, who drives through rush hour traffic, yadayda....the patient stabilizes and they decide to extubate the patient.

And then, I guess, he resumes text messaging his friends. And then he has chicken soup for dinner, which he says is too salty.

*******

Aren't there things that bug you about this picture?

....

So I'm thinkin it was a VT arrest, end of story. However, parent of Fritz is at bedside and parent asks aloud, "But what about all those drugs you're on? You took extra didn't you?" Parent obviously disapproves of narcotics. I ask patient what he's on. He gives me a litany of narcotics. It is enough to kill a herd of cattle, and maybe a few small rodents, too. I assure parent that the son has mediastinal cancer, which is very painful, and I explain the pathophys of narcotic tolerance. The difference between the patient's prescribed dose and the "extra" he took was a single tab of PO Dilaudid. I don't know the patient's pain and narc history, but I do know that it's possible that the "extra dose" is a drop in the bucket, equivalent to a glass of wine for me. Could one glass of wine, after enough on board, toss me over the edge? I suppose it could.

So.

There's a question in the patient's mind as well as with the physicians and nurses of what deadified him twice today: cardiac arrest (from the high K+) or respiratory arrest (from the narcs). But again, no Narcan was done, and the twelve lead EKG shows a wildly unremarkable sinus tach. On the flipside, the patient lives with a potassium of over 5, so who knows how much it would take to send his heart into an arrhythmia.

***********

I'm still thinkin cardiac because, well, if it looks like a duck and sounds like a duck.... I might be wrong. I have RN behind my name, not MD. My job is to treat, not to diagnose. There's a whole lot I am sure I am missing, particularly since I know squat about oncology.

I asked the nephrologist of course. He doesn't know for sure, yet. ("Come on, he doesn't look at ALL like a status post respiratory failure, this guy's had a cardiac event today, don't you think...?" "Yeah, I'm with you, but there's so much goin on with this guy. It feels like that, but it could just be a combination of both.") An hour later, he called me to ask me to change some things with the treatment. He's out supposed to be having fun at a party but he's checked out, thinkin about this patient.

I think the real mystery is: Why was his potassium that high?

* I can't imagine diet alone doing it. (His PO4 also elevated.) I suppose my imagination is limited, but if the potato famine didn't wipe out all of Ireland, I'm not sure diet alone is that efficient.

* He didn't skip dialysis treatments (and his hemo treatments are being done by a source that suggests extremely unlikely that he was dialyzed with an acid bath of 16 or something ridiculous like that.)

* He last bout of chemo (which might have caused mass lysis of cells, causing a flood of potassium into his bloodstream) was three weeks ago.

* His wbcs are low, but I've seen far worse. Infection? Leading to lysis? His lactate was elevated somewhat. ?

* I can't imagine it being so no-brainer as he's accidentally taking potassium pills. This patient has had his life upside down and entrails out for less than a year...he has a polypharmacy stash of narcotics. But I doubt he's like my 70something polypharmacy patient with old stashes of cardiac and diabetic meds that might get mixed up.

* Again with the....Less than twenty four hours post full four hour hemodialysis treatment. Even if the acid bath was wrong, it would have had to be dangerously, wildly, toxic, deadly wrong to produce a serum potassium of 7.3. (Can you even supersaturate an acid solution with that much KCl?) I just don't see a mechanism for that to have happened.

So what did happen?

....

....

I have four days off, which I'm delighted about. But I kinda am really curious about what happened to this patient today.

Mostly, I'm writing this down just to dump it outta my head so I can sleep. Sheesh, it's 0155 a.m. I'm off call in 4 hours. Yay for me.

...My day started at my Home Hospital with a nosepickin, Jerry Springer-watchin, morbidly obese patient who asked me "where the beauty salon is in this hospital." She "needs a cut."

For real.

But then on hospital #3 of the day, I got to Fritz. And people like Fritz, and his family, are the reason I do this stuff.

And then there's the tiny little good things...

2009-01-07T15:07:00.000-08:00

So I go to hook up my periotoneal dialysis patient last night, right, and his wife is present. She usually does this for him at home. I got my mask and gloves and jazz on, and he doesn't have a dressing on his access. His skin's a little red, too. (Red = infection = possibly leading to peritonitis = earthshakingly and life-changingly BAD for PD patients.)

So I say, "Where's your dressing?" The wife blurts out: "YOU ARE THE FIRST NURSE TO ASK THAT IN DAYS! THAT'S EXACTLY RIGHT! HE NEEDS THAT DRESSING ON OR HE'LL GET PERITONITIS!"

Er. Yeah. ? She gives me her own stash of gentamycin ointment and I do a dressing that takes me 5 seconds. But she's very very excited that I'm a "good nurse" who "pays attention" to "the important things." She asks for my boss's name and her phone number, as well as my last name, because she wants to call my boss to tell her what a good job I've done.

Weird.

I mean, that's nice, if she does that. It's really nice.

It's just curious to me because my brain flashes on much, much harder things I've done for people in my nursing career. (The precordial thump that actually worked comes to mind....giving narcan to the woman with stage IV breast cancer....on rehab, the other woman with stage IV breast CA who also had a MASSIVE PE...the man we put in the 360degree turning bed, his wife and the evil surgeon.) I can think of bedside surgical procedures I've assisted with, like the day I held the fully conscious SDH patient's head while the neurosurgeon used a hand drill on his skull....or "Mary", the mother of two with fulminant liver failure and the good GOD Herculean efforts by the entire ICU team.

It's a good list for a four-year-out RN, and every nurse has their own.

A five second completely nothing dressing gets a thank you call to my boss.

Huh.

That's really nice. Nice things happen where you really don't expect them, don't they?

Helping those that do not help themselves.

2008-12-25T17:53:00.000-08:00

Christmas Day. It was my second hospital today with the second emergent admission for the second patient who skipped dialysis this week. Patient #1 was short of breath, chest pain. Patient #2's potassium is 7.9 and he has EKG changes.

Big fat duh to both.

As I am not a Christian, it wasn't my holiday and I don't actually mind working it. I do every year. Almost everybody is grumpy today because most people want this day off. (Kudos to my nephrologist for his grace under THREE attempts to go home only to have callbacks to the ER for the same exact stuff.)

Christians believe they are rewarded for taking care of people who refuse to take care of themselves. That reward is in heaven. I'm not going to heaven. Sounds nice and all, but I'm a lazy buddhist. My reward is ...breathing now. And typically, a paycheck. Nice and fine, but you can't take it with you and it's spent by mid-month on bills, anyway.

The point is that taking care of people who expect me to clean up after them is exhausting. I'm struggling today with finding my buddha-heart of compassion.

I am struggling not to say DUH! at the top of my lungs. I am biting my tongue from saying What Did You Think Was Going To Happen, Exactly? I am struggling with, If You Were Trying To Die Over Christmas (And You Might Have Been), You Don't Go To The ER When The Symptoms Start....You Sleep Through It.

I didn't get that guy who developed diabetes at age 3 today, or who was born with congenital polycystic kidneys. I got fat bastards who wanted to drink and eat and be merry all week and held off on following their physicians' advice until after Christmas dinner was over....and THEN made it my (and said graceful nephrologist's) job to fix them.

ESRD patients are all Medicare, did you know that? You and I pay for every last one of my patients. Some days I wish they would meet us half way.

This is a public service anouncement

2008-12-03T17:59:00.000-08:00

If you're going to attempt suicide, at least don't be stupid about it. Here's a tip:

DRINKING ANTIFREEZE IS STUPID!

Chances are excellent you'll wind up doing something stupid. For example, you might sit in the corner of your bedroom and rock back and forth and giggle. Your family might notice this is strange and before you actually die or respiratory failure (which, just so you know, TAKES A WHILE after you drink the antifreeze), they might call 911. EMS will get you to the hospital just in time to jam a tube down your throat to ensure your continued survival.

Or you might become addled and fall down your stairs and quite possibly THIS won't make you die. It won't even make you brain injured. But it will make your nose crooked and put scars all over your face so that EVERYBODY you see henceforth will ask you: "What happened to you?". This will likely make you very uncomfortable and might not nearly have the musical swell and soft focus you were envisioning.

The EMTs, the nurses, the doctors who bring you back from said suicide attempt (because you did not have a DNR) will not ask questions about your suicide attempt in a hushed tone of voice. We use normal tones of voice. It's the holidays and we have heard this story. We just stopped you from dying. Sorry, that's our job. If you'd chosen an alternate method, we might have not had such an easy time of saving you.

I'm not saying your life doesn't suck. Not at all. I'm saying your life is not the only one that sucks. It's the holidays. Get in line.

I find it interesting that the two ethylene glycol ingestion cases I've had just this week were not done in the "city" hospitals in our area, they were done in the Four Seasons Hospital in Cul-De-Sac Haven of Affluence, Colorado and the Hospital Hilton of Gated Community, Colorado. I'm not implying that money = less depressed or has less cause for depression. I would like to make the point, though, that if my patients had been further down the socioeconomic bracket, at least I could argue that they might have had less access to Google, PubMed and Wikipedia.

Fortunately or unfortunately for my depressed patients, ethylene glycol (like most alcohol-esque substances) dialyzes out very quickly. It might cause permanent damage to say, your kidneys, and now you're an end stage renal patient dependent on dialysis for the rest of your life.

And you thought you were depressed before.

I mean: GOOGLE IT, PEOPLE!

Duh.

And if you didn't catch that before:

2008-10-31T20:51:00.001-07:00

Thanks, StrongOne for the embed....I'm passing it on, too.

(My first youtube post. Neat.)

You all WILL be voting, right?

2008-10-28T15:18:00.000-07:00

To US citizens who might be trolling by....

Check this out, which was worth 75 minutes of my time. (Actually longer, since I did read the book, also worth my time).

here

And at very least, love of god, go vote.

On the upside, you get this warm fuzzy feeling that you did the right thing. Bonus, you get to guiltlessly complain about political decisions for the next four years.

If you don't vote and are over age 18 and a citizen, get the hell out of my country. Move to Zimbabwe, where they aren't inconvenienced by voting.

Specialty BLS

2008-10-26T12:10:00.000-07:00

RehabNurse asked me a question: did the ICU help me get into my new niche, dialysis. The short answer is yes, I did.

The slightly longer answer is that in many ICUs, patients require dialysis just like anywhere in the hospital and because they are so critically ill, it must be slow (i.e. 24 hour) dialysis. It's called CVVHH or CRRT...continuous renal replacement therapy. Which means the ICU RNs run the machines all day/night until one of two things happen. (The dialysis nurses actually understand the machine, test it, maintain it, and handle all access between the machine and the patient.) (There are excellent reasons for this division of labor.)

Reasons for stopping slow dialysis are: the drug the patient ingested is gone, their kidneys woke up and they're now making/clearing urine or the patient's heart (read: blood pressure and HR) can tolerate a regular speed hemodialysis treatment. Then the dialysis RN comes in and does the specified hemo treatment at the ICU bedside.

I loved doing CRRT while I was in the unit. Some ICU nurses love the ICU because of the adrenaline. I loved it for the multiple organ system failure, the very sickest of the sick. When we're still doin everything possible, and one system after another fails, dialysis becomes inevitable as do pressors. My unit's resource nurses knew I loved the 1:1 CRRT patients, so I got them often. (Some ICU nurses hate doing CRRT.)

But anyway. RehabNurse's question, and doing my BLS renewal today got me thinking about nursing specialties. I got the dialysis version of BLS today, which is new to me.

I've gotten the rehab/SCI/TBI version of BLS, which is BLS plus How To Do Compressions On A Patient In a Halo and Love Of God, No Chin Tilt, Jaw Thrust Only!!!

The critical care version of BLS: Yawn. Just tube 'em.

The dialysis version included: Pump the blood back manually. Put their legs up, open the saline wide. If it's an air embolism, it's entirely your fault...left trendelenberg and pray. And if you shock 'em while they're dialyzing, you'll fry the machine.

What's your version of BLS?

Not loving....

2008-10-25T20:41:00.000-07:00

....the call at 0615 this morning to ask where I am. "Er. I'm in my bed. Why?" Thought I'd clarified that schedule change a week and a half ago. Apparently not.

Miscommunication rampant in my new role. Not loving that.

*****************

Have to re-do BLS tomorrow (Sunday) because I can't find my current card (though I have the current ACLS card). (Why I did not put these two things together in my wallet? I don't know.)

Brushing up on Another One Bites the Dust...

Client.

2008-10-14T16:29:00.001-07:00

Much to tell about dialysis and my new role, very excited. But with the little time I have today, I have to tell you about the first part of my morning.

I am no longer a "staff nurse." I work the bedside in a consultative role. I provide a service, namely dialysis, to patients who need it while they are staying in the hospital for whatever reason. And ESRD patients have a lot of reasons to be in the hospital. I have been on orientation (and still am) since early September mostly because we cover twelve area hospitals, and work alone. Each hospital is different; each system has its own rules and protocols. I don't use a timeclock. I get my to-dialyze list the night before and I go to whichever hospital needs me.

I have a LOT to tell you about why this is the coolest thing since cheese was invented.

A quick story:

This morning, I woke at 4 (which I hate, but will change). I drive 20 miles to a hospital across town to meet my preceptor. First on our to-do list is a young woman who is on periotoneal dialysis. We check our supply room and paperwork on the ICU first. We sneak quietly into her room a little before 6, and D is teaching me about the peritoneal dialysis machine. I know the physiology behind it, but I'm learning from him details about what concentrations of dialysate might be used for what conditions, what dietary restrictions PD patients have (and don't), and how the machine is set up. I'm learning about how the patient cares for herself at home, what she does, what she has to do to modify her life to do her own treatments.

The machine looks good, the treatment is complete. We take down the numbers we need and assess the output of the dialysate, talk about what it means, what I'm looking for.

The patient wakes. She's used to seeing dialysis RNs at this time of day. We introduce ourselves, ask about how her night was. We discuss her concerns about treatments, what she's discussed with the MDs, what her plan for her self-care is, how she's going to do this in conjunction with her ICU and floor nurses (who don't know how to use PD). We mask/glove/etc up, and disconnect her.

She has concerns about her dressing, and we do a sterile change for her. We discuss another of her comorbid conditions, ask how she's managing. After that, she has no other concerns, seems to be doing fine (telemetry and vitals all show stable). We bid her a good day.

We visit with the patient's ICU nurse, ask the nurse similar questions. We talk about what we did, and educate the nurse about the dressing, some basics on the machine, discuss the patient's plan of care today, her labs and meds. We're happy, the ICU nurse is happy, jots down some notes to pass on for the next shift. We borrow the chart and write a progress note, enter a charge into the computer then compile OUR paperwork.

Then we thank the nurse and head out the front door by 0730, on our way to a different hospital.

....

I. LOVE. That. Go in, assess the patient's needs, provide a helpful service or two and usually some teaching. We even help the nurses that are at the bedside of the patient, even sharing some new information to them when they're open to it. (And we nurses generally are curious about new things.) (Can I give this blood pressure med? Will this dialyze out? Does this dressing need to be done with sterile technique?) We didn't interact with the physicians until later today, but that's part of it, too. Chart, charge, bad-a-bing, out the door, on to the next consult visit.

I LOVE that.

Yup. Think I might love this job.

Good money as a nurse.

2008-10-13T17:06:00.001-07:00

Listen up.

Kim from emergiblog pointed to an article here about why nurses don't stay in nursing. Go check it out first.

Kim asks us whether or not we've "bought in" to nursing. She loves nursing; I get that. She is committed to it; I get that. I respect these views. I love nursing, too. Her question is: have I "bought in?" It's a broad question, and I suspect she's asking Will I leave this profession in five years? I don't know, maybe. There's great stuff about it. There's very stupid stuff about it, too.

I got a lot of jest and harrassing when I left the ICU to dialysis. Snickers of: "Ah, she took the lure of the money." "I thought you wanted to be a *good* nurse." "Isn't that boring?" But a lot....A LOT of the jesting was rooted in cracks about the money. I want to speak to Kim's open-ended question and to the jesting about money I got.

Have I bought into antiquated ideas about self-sacrifice? No. Have I bought into the idea of more education for lower pay? No.

Personally, I find that entire system retarded. I'm sure Kim does, too. I'm going to offer one primitive solution to the problem, however. One bedside nurses who do not believe they hold any fiscal power can do to help themselves. But it can help you, and can help your fellow nurses, too.

My idea is: Talk frankly about money. Simple, huh? And yet, completely taboo in American society.

Here's the problem:

I work for a paycheck, period. I'm a buddhist, I don't get a saintly reward for my butt-wiping today. For all the times a physician tears into me for insisting on pain medication for a patient. I happen to like my work, but would I do it for free? Are you insane? It's HARD WORK.

You don't work because you're a good person. You work for a paycheck. You are in all likelihood a good person who works for a paycheck, but you don't work for the sheer joy of dragging your butt out of bed in the morning. Because you work hard, too. With body fluids. And people who call you four-letter-words. And do not have manners.

WHAT IS WRONG WITH NURSING THAT WE EVEN HAVE THIS MYTH THAT WE AREN'T WORKING FOR A LIVING? The myth is that we do it for fulfillment. Great. Why is fulfilling mutually exclusive to well-paid? Trouble is....If nobody can be blamed for that stupid idea, why do RNs not hold those cutting squeaky checks accountable for believing it?

Here's my rationale:

I learned many lessons in computer consulting. One of them was I learned to talk about my billable rate/salary. I think it's something many men, regardless of profession, do and understand. Talking about the salary. It's how, in computers, you know what the going rate is. How much do I charge for my services? Well that guy's makin this amount and he's out of school and knows nothing and nobody, and this guy's got ten years on me, so somewhere down the middle might be a start. Factor in such things as whether or not I've got competition, whether or not I'm trying to underbid or whether I expect my client to agressively haggle my price.

Talking about the money is expected in IT. No one functions without it. It's frequently handled with some subtlety....there's typically contract obligations about discussing your rate. But you can talk about the rate you got from your last client. And you can say whether, with this client, you're doing better or worse. You can mention whether or not there are perks.

Women often don't do this.

It's stupid of us.

Nurses don't usually do this (though I notice male nurses more often do). I don't get why. CNOs talk. Why shouldn't they? It is my belief that in my region, this network is a large part of the reason that salaries are so uniform across the region's hospital systems. They have information. So should you.

*********

I am under a contractual obligation to not tell you my new pay rate. So I won't.

So lemme tellya some facts about the hospital system I just came from. I live in Colorado, and my state pays BADLY across the board. Because it's so great to live here. Doesn't matter if you're a staff nurse, nurse practitioner, or traveler nurse. Travelling nurses often have the advantage that they can hop onto their company's website and compare payscales across the country. I love these guys, because they're happy to share this information with me. Ask a traveller not what s/he's makin, but what travellers expect to make in your city and in other cities s/he's been to. You should know.

New grads were offered $22/hr last year in the two biggest hospital systems in town. The nonprofit in this town (not surprisingly) pays a pittance better than the for-profit. At the nonprofit, there's a salary cap on experienced nurses at $38/hr. (Don't know the other's cap.) Raises are neither competitive nor performance-based. Expect 3% annually if you showed up most of the time, and there is no automatic cost-of-living.

In 2006, I started at a base of $20/hr. Who knows if this trend of roughly a buck a year better new grad offering will continue. Nurses already at the bedside who have experience do not keep up with a 3% flat increase. A new grad hiring in would have surpassed my base rate by next year, had the trend continued.

And don't think that didn't make me sore. New grads should make good money; I don't begrudge them a good starting rate. Experienced nurses should make more.

Want to know what payraise to expect when you're interviewing? Few interviewers or managers will tell you because they can't promise or it becomes contractual. Tell your interviewer you'd like to shadow a nurse on the unit you are shopping to work for. Then ask him or her. (Perhaps for a pay range if that's an easier question, or the typical annual percent for raises then you do the math.) If she prefers not to discuss her pay, ask another nurse you bump into in the med room.

This needs to be normal for us. We all win when it is.

Travelers can expect about three bucks an hour or so more than the poor slobs who work as staff. With no benefits. It's almost not worth it, unless you really are here to ski/board. Stiff competition to travel in Colorado in the winter months.

Expect a night shift differential of $5/hr, double what some places pay. Expect to be nickel and dimed where that night diff ends up being only 7.5 hours of a 12 hour shift or some crap. Ask the details. Expect $2.50/hr for weekends (and that seems common). Again, look for fine print on what 'a weekend' means. Often, how the business defines weekend is not what a normal person calls a weekend.

Same thing for holiday. Don't believe the allure of Double-Time For Holidays when you work night shift. It's typically half of what you think it is. Four hours on Christmas night and eight of Christmas Eve, so you'd have to work both to get your full double-time. Human resources only does these deeply-stupid sounding schemes to save money only because we don't hang them from the rafters by their ties for it.

Why don't we mention to them that we can? We know CPR and they don't. We won't let them hang until the point that their airways are r e a l l y compromised, right?

I am not aware of any hospital in town but (possibly) one who offers a diff based on your education (ADN v. BSN). I don't know how much it is, but they do have a structured clinical ladder that includes education and meeting-attending. Some hospitals pay tuition benefits, but ask how much and then compare to the cost of a credit hour. (You may find a gap.)

At least one managerial position in my system offered between $25 and $36/hr based on experience, requiring 24h pager. (I actually laughed, and no, my girlfriend of 25+ years experience including strong managerial background plus BSN and two credentials didn't take the job.) (Are they mad?)

I am not aware of sign-on bonuses currently offered in the biggest hospital systems in town. I suggest you ask about bonuses during your interview process because if you don't ask, it will never be offered. The worst that you can hear is 'no.' Because you know they want to hire you, so you have nothing to lose and potentially a lot to gain.

Rumormill has it, the best paid hospital nurses work for local government. Rumormill also has it that those nurses love their benefits. The local government's hospital website LISTS base offerings. It is the best paid hospital system, by average, in the region.

I know of no hospitals except possibly pediatrics in town that pays for specialties, such as critical care.

********************

I went to work for a private company that offered a salary based on my years as a nurse. I left my base AND my night differential behind and am still ahead.

Most surprisingly to me, my organization has clinical measurements for GOOD PATIENT OUTCOMES, and the employees at my hospital ARE PAID BONUSES WHEN PATIENTS DO WELL CLINICALLY. How cool is that?

Nurses at my new company are sometimes embarrassed about this when they talk about it in my orientation, feeling like we shouldn't be so happy about our bonuses.

Why

the

hell

not?

If our patients are clinically doing BETTER, and are FEELING BETTER, are able to lead fuller and healthier lives, that means we are DOING OUR JOBS WELL. How exactly is it wrong for us to get a bonus for a job fantastically done? Is the only thing motivating me money? Of course not. I'm a nurse for chrissakes. If I wanted money, I'd have gone to be a specialty surgeon. I want my patients to do better because I like them. But that my company pays me a bonus for doing a good job means that I am MUCH happier doing my good work for that company rather than some schmuck hospital Scrooge that's gonna nickel and dime my overtime on Christmas.

What could be better? Heck, yes, that makes me likely to stay working as a nurse five years from now. Not only that, but likely to work as a nurse working for this company. Essentially, if my patients get better, I make more money. But I make a good salary no matter what (because patients are patients, and my company appears to understand that concept, too.) What a thunderingly win-win wonderful idea.

***************

Why do I tell you all these things? Because it's the most normal thing in the world to want to do good work in your community, be a leader in your world and promote the health and well being of others. And also want good food on your table for your own family, gas in your tank, money to vacation, and some socked away to retire upon, much less all that you owe paid off.

So that's my big idea: Talk (mindfully) about your salary. And for god's sake, when you go shopping for your next job....remember that YOU are shopping, and get a good deal for yourself.

Don't simply buy in.

Be an educated consumer instead.

Retooling.

2008-10-04T14:31:00.000-07:00

Long time, no post. I know. In the remote possibility that somebody out there is still paying attention, I'm going to explain my hiatus.

I left the ICU at MyHospital. I am now retooling to be an acute dialysis RN.

Much of the reason I couldn't blog was because first of all, I was negotiating a new job. Other reasons I couldn't blog:

Lots of hospitals have ICUs, and calling MyHospital MyHospital and changing a handful of details about patients was easy enough to be HIPAA compliant and protect everybody's privacy. There are a lot of ESRD patients on dialysis....but few dialysis companies. And I need to rethink and be more cautious in my tale-telling than I had been before. I'm really very excited about the new digs, though, and I can't wait to tell stories. I just need to probably change many more details than I had to protect everybody, and there's likely stuff I can't talk about at all.

Also, as I was leaving MyHospital, several large nails were pummeled into the coffin that contained my decision to leave there. Two reasons had me spitting bullets angry. One was a patient story wherein I feel that a physician should have been shot. Not because of any malpractice or negligence on his part, but because he'd flunked Compassion 101 in med school. It's a story every ICU nurse out there can tell about a patient 100 times over. At MyHospital, working with this physician and his group is regarded as an honor....a crowning moment in your nursing career...when you can be A Heart Nurse. But after this patient, I don't want to work with that man.

And finally, there were some management problems that I may be able to talk about now with fewer expletives. I've skirted around that issue in this blog before, and have finally had to drop off discussing it. I had a direct conflict with upper management over a patient safety issue. There isn't a nurse out there who's going to think cutting staff AFTER a sentinel event and subsequent Visit From The State is a good idea. Sane people do not think this way. MyHospital does. I had taken care of the patient, and I sent an angry (though expletive-less) email over some people's heads. I was hauled into the principal's office over "my way of communicating." I was told I offended people by suggesting that "anybody had forgotten the patient's name". (Which I dropped repeatedly in the email, lest they forget that a woman died and she has a name and it is Insert-Name-Here.

See? Me and my rude communicating. So I've got a lot to get caught up on. Been a busy two months.

So I'll be checkin back in more often.

Breathe, dammit!

2008-08-15T07:07:00.001-07:00

I did a precordial thump this morning when my patient went into VTach.

And it...WORKED!

Holy crap!

It's one of those annoying things about medical television is the frequency with which they do precordial thumps. And they always work on tv. And the doctor (it's always a doctor...when it reality it is more frequently a nurse or EMT) predictably says: "Breathe, dammit! Breathe!" And on tv, they keep thumping. In reality, you thump once and then you shrug and say, hey it was worth a try. And then you get on with the real business of undeadifying your patient.

But I thumped the guy and it FIXED HIM!

It was so damn cool, I was giddy for the rest of the night.

The intensivists are now calling me Thumpa.

Sedate my Dad, please...

2008-07-16T23:15:00.000-07:00

Vented patient coming off a day of significant hypotensive problems secondary to sedation medication. Patient now awake, alert, calm, cooperative and self-reports pain-free. VSS, trend with sbp low 100s, pulse high 90s to low ST.

Daughter at bedside and has been at bedside for the entire day. Pt appears entirely comfortable and a million bucks better than the day before. It is 9p.m. She says: "Can't you sedate him more? It's only at.... (she reads a number off a pump) 12."

I ask patient, "Mr. Smith, are you comfortable?"

He nods, ET tube in his mouth. "Pain level okay?" He nods again. I say to his daughter, "I'm all about letting your Dad get sleep tonight, but I'm all about keeping a blood pressure for him, too."

"But his blood pressure says (she reads another number) 115 over 40."

"Yup. He's also wide awake now. People have a lower blood pressure when they sleep. He'll probably drop another 20 points once you guys head out for the night and he drifts off to sleep. If he doesn't get to sleep, I'll up the sedation. One of my goals for tonight is that he get some good rest, since he had so little last night." I speak to her and the patient, and as I say the last I smile at him and nod. He smiles and nods back. He understands our plan.

She also wanted to argue vent settings with me, arguing that he DID turn and move today, and that obviously it was enough. (As I listened to rales and rhonchi throughout that were not there yesterday.) Argued that he didn't need more oxygen, argued that He Was Weaning Fine A Few Minutes Ago And Didn't Need It.

You know... I know you're worried. I know you're freaked out. I know you're hangin onto your father's hand all day like he's a dyin man. Lucky for you, he isn't a dying man. His prognosis is good.

And you appear to be the kind of person who needs somebody to boss around so you feel like you're in control. Even though you have no idea what you're talking about and you don't seem to want to listen to me or anybody else.

I know that you don't mean to be such an a$$hole to the closest target, i.e. me. I know I'm part of the solution that your dad's gettin better and what's nice is that your dad appears to know, too. I can see your father mouth 'thank you' and smiles and nods with a thumbs up. I like your Dad; he's a nice guy.

Tonight, I was too tired to find polite and kind and unobtrusive nursey ways to say that to you. Because some days I actually am too tired to find compassion for someone who insists on arguing with me nonstop before I've had my first fscking cup of coffee. Over completely retarded shit like My Dad Doesn't Need More Oxygen that are so dumb I'm amazed that a seemingly normal intelligent person like yourself doesn't realize how bratty you sound when you spit that out at me.

The right way to deal with you is talk to you as if you are already know everything and are totally in control of the situation while I explain every miniscule part of what I'm doing and how it contributes to the pathophysiology of your father's case. I'm a woman and I've been married. Even if I weren't a nurse, I already have useful skills in dealing with this situation. You are being simultaneously petulant, stubborn, and just plain stupid.

But I don't have it in me today and you're being a real b!tch while I try to do what your father needs me to do. I am a long way from being a bodhisattva, much as I'd like to be that person. I'm human, and some days I get tired of that bullshit that a nurse isn't allowed to have a bad day.

(Thank you, Johnson and Johnson campaign, for reinforcing the ridiculous myth that nurses are martyred saints instead of professional clinicians:)

I'm not even havin a bad day. You're just bein a b!tch. Your father is a genuine pleasure to take care of. He shall have superb nursing care tonight. I will sit outside his room ALL NIGHT and make sure he's stable and comfortable. Even if you're dad wasn't a sweet man (and he is), he'd STILL get superb nursing care tonight.

Now get the hell out of my room.

Then AFTER the sentinel event....

2008-07-14T17:03:00.000-07:00

A patient COR'ed under... well... a horrible set of unfortunate circumstances two months ago. I'd been involved with the case and had blogged about it, but I've since removed that post. Seemed like a good idea, what with all The State Inspectors coming through and forcing some policy changes.

Steps were taken fairly immediately to change some staff roles. The State told us to do it, and for once, a governmental body stepped in and said the right things. The changes were good steps, to the RNs view. Essentially, we added staff in ancillary roles to increase patient monitoring. Yay for the patients! Yay for us!

In the short term, nurses filled those roles. Nurses were more than willing to accept the inconvenience for patient safety. The state inspectors were apparently satisfied with our change. We were glad for the role change/addition. We were thinking that more ancillary staff would be hired to fill the ancillary roles, and then we could get back to the bedside.

Exit state inspectors.

Then, we hear that there are more changes under discussion. First, the number of patients for each ancillary staff to monitor doubled. Then the ancillary roles were physically moved away from one of the units. Then discussion was underway on whether to add more patients from two entirely different floors for the staff to watch.

I had a hissy fit.

I sent a scalding email to my manager and the CNO. I talked about the patient that died. I mentioned her name, I talked about her family, and the tone of my email implied that SOME of us had forgotten and we didn't care that she was dead.

I talked about the logistics of the proposed changes being dangerous. I talked about what is GOOD on our unit, what WORKS on our unit, and the difficulty of these proposed changes being feasible. I hammered at how unsafe these changes appeared to be for patients, and how unsafe I would feel leaving my license to this system.

I was pretty hot.

So my manager pulled me into her office days later. She was upset and hurt. Why did I write an email criticizing instead of coming up with positive solutions? Because it sounds like the decision's done, and you never solicited suggestions at any point.

How can you suggest I didn't lose sleep over that woman's death? I'm sorry, I was angry and honestly, this looks like a decision made with a bottom line in mind, not patient safety....Of course you lost sleep over it....everyone involved in the case lost sleep over it. However, I said, I don't like this decision. I don't think it's safe for patients. I'm sorry you are hurt by my tone, but I feel very strongly about this one.

Hopefully, the meeting at least allowed her to get what she needed to off her chest. I apologized for implying she didn't care. I didn't apologize for finding the new policy changes flawed and dangerous.

I was requested to meet with my manager's boss, Director. (This woman reports to the CNO, so technically I guess I went over her head.) So I went. The director doesn't like my way of communicating. O....kay. (And?)

I broke chain of command. Yes. I've known CNO for a long time and feel comfortable going to her....I just met you two months ago....CNO has always said she has an open door. Director said, Of course CNO has an open door, she's a very caring person, but if you have issues with this unit, you can come to me before you go running to CNO. (Direct quote, that one.)

I told her I didn't like the proposed policy changes. She said the state made her do it. I said: I liked the changes that happened after the state went through...it's this new stuff I don't like. She asked if I'd worked in other ICUs, where things worked differently. I haven't and she knows that. Director said that in her x number of years of experience that she'd never seen nurses be so lazy and rely so much on ancillary staff.

Wow. ....I was struck so stupid by that I don't remember if I even responded to it.

She outlined her ultimate plan for the unit, and parts of this plan do appear to have some positive things about it. I still don't like the fact that the ancillary staff will be monitoring 40 patients apiece, including both ICU pods, and a new ER chest pain center.

She said I could come to the meetings "with concerned staff members" and take part and be "part of the solution." The qualifying factor is that I was chair of ICU's nurse practice council, and was part of the hospital's unit practice council for 18 months....being "part of the solution". I quit two months ago because nothing had changed in that 18 months.

I'm also wondering how she concluded from my angry email that I was promoting RN laziness by asking for adequate ancillary staff. (This picture of yet another lazy RN to the right.)

I promised her I wouldn't go "over her head" again. I will keep my promise.

....

I called another company the very next day and left the message that, You know, I'd told your recruiter I was only interested in prn at this time...and I think I've changed my mind and I'd like to talk about a full time position. Could you have her call me back please?

i need a drink.

2008-06-24T04:24:00.000-07:00

We have, on the unit right now, ....

not one....

not two....

not three...

not four...

but FIVE SCREAMERS TONIGHT.

There is not enough Haldol in the world right now. Or Dilaudid. Or Zofran. Or Phenegran.

And for me, there is not a martini clear or near enough.

F I V E.

We had one call the cops on us. Unfortunately, they did NOT come to take me away.

Nurses Who Love Their Jobs.

2008-06-09T21:57:00.000-07:00

I talked to two nurses who love their jobs today. You know how great that is when you hear stories about somebody who genuinely loves what they do? Of course you do.

Laura is an ER nurse who happened to float to the unit today. She's a vivacious (no really, that's the word) brunette, a little shorter than me, bright brown eyes. Very cute, roughly my age. She doesn't mind these messy ICU train wreck patients, and she can obviously handle them. But what she loves best is "keeping as many balls in the air as I can at one time." That's her talent and her love: juggling this that and the other thing and taking care of lots of different people with unexpected medical problems. She talked with enthusiasm about managing chaos. That's what she takes pride in....the ability to think fast, think on her feet and to react quickly to things.

And it makes her happy. How cool is that?

Sariah is a nurse who was finishing up hemodialysis on one of my patients when I came on shift. Sariah has coffee brown eyes, and she wears a modest scarf to cover her head. Her manner is always calm and soothing, unhurried. She loves to teach...anytime I've asked her a question about the workings of the dialysis machines, she's been wonderful about stopping and thoroughly explaining things to me. Now, I've been sending out feelers for other additional job opportunities, so I thought I'd ask her about what she does. I love CRRT...maybe I would like doing dialysis on an occasional basis. She really perked up when I asked.

She's been doing dialysis for over 30 years, she said, having started in general ICU. What she loves is knowing pathophysiology deeply and understanding that when she assesses a patient pre-treatment and finds a K+ of 9.0, she watches the change in the T wave on the EKG lead as she treats the patient, watches it improve as the dialyzer filters. She listens to the patient's lungs after she begins treatment and hears improvement, sees their breathing become easier, more relaxed. Dialysis is easy, she says! You should apply! It's wonderful to be involved in watching a patient improve, and so many of them recover so well after transplantation. She just glowed and it was obvious the great joy she gets from directly helping patients get better.

That was just so. Awesome.

And you know what? I'm having a great night. It totally set my night. Because I gotta tell ya...I LOVE ICU. I love sick as snot patients, people that have complex crisis needs. There's not a patient I take care of that isn't in the midst of a big turning point in their lives. They're not only sick but afraid, and in the midst of hard decisions. I love that I need to understand extreme pathophysiology: not that I don't have volumes to learn, I most definitely do. But I know that the body is likely to break in a handful of ways, and I know how to start getting a handle on those things emergently. There's always ways for me to learn more deeply. The deeper I learn, the better care I can provide for my patient clinically, and the better help, reassurance and knowledgeable resource I can be for families.

Laura was telling me that I'm a "good ICU nurse" because I'm "obviously a control freak". I was telling her that I love doing CRRT, really enjoy tweaking this drip to change the central venous presure here, futzing with the dialysis rate to improve this lab here, focusing on ONE patient at a time, and understanding that patient comprehensively and completely. Knowing their history, understanding the messiest of pathophys. Love it.

I'm good in a crisis situation, too....last night both of my patients had severe respiratory decompensation within the first hour of my arrival: one got reintubated, the other CPAP. I can do that. But unlike the ER, I don't want to leave those patients after the initial crisis is past. I'm happy talking to the family members about what happened, how their loved one is, what to do now, how recovery will look.

It's silly, but I'm a clean freak, too, and I do like doin that nursey stuff and giving baths and providing that fluffy comfort too. Don't ask me to do it for seven patients in a night...(screw that), but for people THIS sick, THIS fragile and suffering THIS much... Years ago, I was in a car accident and I got a free trip in an ambulance. One thing I remember is that hours later, my parents had seen me, a few friends had seen me...and my then-roommate Kelly arrived late that night. She said, "You look like shit, man." And she wiped the blood off my face. Nobody'd even told me I had blood all over my face. I'll always remember that stupid kindness of wiping the blood off my face. That stupid kindness of You Look Like Shit Man.

I know now all about prioritizing: airway, breathing, circulation is what I do. The most important things I do. But when my patients are stabilized, none of them ever have blood on their faces or anywhere else.

(Don't tell anybody. I don't think that fussy stuff is fashionable among professional nurses anymore.) (Doesn't mean I don't love looking up new drugs I don't know to learn the pharmacological effects on blood pH and other neato stuff.)

Yeah.

I love my job, too.

Cool, huh? I hope you love your job, too, some days. Pass it on if you do.

My dumb government.

2008-06-03T14:59:00.000-07:00

Found this over at ERNursey: Home dialysis is available now. Something Medicare will only pay half the cost for because they'd rather pay the more expensive full cost of hospitalization.

Do I write to my Congressperson to fire the hell out of these people or is it my Congressperson that I need to fire?

Proof of job security, #749

2008-06-01T22:20:00.000-07:00

Patient in ICU has had type 2 diabetes for years. Family at bedside. Sugars "out of control" high. Physician chooses to write for subQ insulin, which RN gives.

Family goes home after dinnertime and gradually patient's sugars plummet.

Turns out family had been sneaking the patient candy all day without telling anyone.

This has happened to you, too, hasn't it. (Notice ungrammatical lack of question mark.)

Why do we keep interfering with natural selection?

A rare slow night in the ICU...

2008-05-26T02:19:00.000-07:00

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

2008-05-24T01:26:00.001-07:00

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.

2008-05-20T00:29:00.000-07:00

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!

2008-05-18T22:33:00.000-07:00

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

2008-05-13T20:19:00.000-07:00

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.

2008-05-13T03:18:00.000-07:00

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.

2008-05-07T21:32:00.000-07:00

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:

2008-05-07T20:29:00.001-07:00

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

2008-05-04T02:42:00.001-07:00

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.

2008-05-02T04:11:00.000-07:00

...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.

The Republican candidate....

2008-04-30T18:44:00.000-07:00

Gotta say, McCain is not impressing me by asking Big Pharma and Big Insurance to do all it can to reduce health care costs for the average America citizen.

Really, Senator McCain? Come on. Really?

Does that BSN really matter?

2008-04-25T01:46:00.001-07:00

My hospital got new name badges printed this week. I work for a big hospital system.

I do not yet have my CCRN certification, but I do have my BSN. I want my name on my name badge to read: JustCallMeJo, RN, BSN

I was assured that this would be the case. It's not. When my colleagues and I received our new name badges, we were all just RN. Nobody's certifications, nobody's educational degrees (and a handful of us in the ICU are master's prepared, too.) (Yes, bedside nurses with master's degrees. Smart practitioners who actually want to take direct care of patients. Whaddya know.)

I emailed the CNO. I was hot. My CNO is doctoral prepared. I said I hoped they'd gotten her badge right; and that I'm sure that I'm preaching to the choir on this issue, will you please fix it? I'm only asking for ONE of my bachelor's degrees to be printed on the badge. Just three letters, not six.

My CNO told me and the rest of Nurse Practice Council on Monday that certifications will be printed, not educational degrees. I thanked her for responding to my concerns first. Then I asked why. "Because with the font size, the names will be too small."

Now she knows as well as I do that the pompous Hospital Mission Statement is printed in fine-ish (9 point) print on every single fscking name badge.

But the font would be too small if 'BSN' or 'BSN, MSN' were added.

Because. The font would be too small.

....

Ask me, now, why I don't trust upper management? Why I don't think they have any CLUE what is important to me as a clinician?

I am simply....RN. A nurse is a nurse is a nurse, right?

Take your Magnet and cram it with a Flexiseal.

p.s. And why the hell do the exam certifications get the corrected dispensation and the 4- or 6- degrees do not?

I'm back.

2008-04-25T00:53:00.000-07:00

Hi all (if anybody's out there). I'd taken a bit of a hiatus from blogging over here on Sinus. Some life stuff was more important. You understand.

But I'm back. I've fixed some broken links to other bloggers who've had life take precedence over blogging, and have found some bloggers new to me that I'd like to add to my blogroll.

I also am looking for recommendations on a blog reader that people like. I think I'd blog more, read more, if I didn't need to click everywhere and forget to bounce to other places I like to read. Suggestions, anyone? (Assuming there isn't a big fat echo out there....which is likely....)

/jo

Beer does this.

2008-04-22T22:21:00.000-07:00

Dear patient,

Your husband wanted to take a picture of this room today.

What would that photo have showed? You are lying in a hospital bed, with your wrists tied down. Pillows are stuffed under your back because I turn you side to side all night.

There is a blue tube as thick as my middle finger down your throat. It is connected to a machine, 4 feet tall, that breathes for you. From those tubes are two very fat tubes, a white one and a blue one. For air going in and air coming out. Also, a thin wire attaches to the knot at the end of your endotracheal tube and goes to the monitor, so that I can watch numbers that are relevant to keeping your body's pH balance stable.

You have five electrodes attached to your chest, which is attached then to a tv screen over your bed. It shows me your heart rate and rhythm. Another cord goes to the blood pressure cuff on your arm.

You have a thin tube down your nose. This tube goes into your intestine, and comes up and out and is connected to a small pump, which is connected to large bags that are giving you amino acids and sugars. The box tells me that it has milk proteins, sunflower oil, medium chain triglycerides, cellulose gel (insert 34 other chemical substances), and corn syrup and vanilla flavoring. It smells like soymilk with fake vanilla sweeter. Which, I suppose it almost is.

There is a much larger tube going down your throat and into your stomach (you have two tubes in your mouth, see). This one is suctioning out the acid. Green crap is coming out intermittently.

You have a foley catheter in your bladder.

There are two photographs here of the same thing because you needed all six loaded with different medications, programmed differently by med, by how that med is measured (mcg/kg/min and ml/hr and units/hr, etc).
You have an iv line with what we call a "chicken foot" on it. That means we don't have enough iv ports for all the meds you need. I am pumping phosphate, magnesium, heparin (a blood thinner), and an ungodly amount of sedation and pain medication.

You also have a gigantic 2-tube catheter going into your jugular. EACH of the two is almost the diameter of my pen. One of those tubes is slurping all your blood into it and pulling it into a dialysis machine larger than my dishwasher, but smaller than my fridge. This is scrubbing your blood with acid and base baths, respectively. The waste is going through several pipes thick as my big toe (all of them), and dumping it through that huge port in the wall. God only knows where it goes there.

This dialysis machine requires that I count every milliliter of fluid I am pumping into you (however it gets there), and every milliliter that I take out to try and meet the goal of fluid we're trying to take out. Every hour on the dot I flush this machine with saline so that you don't throw a blood clot and the machine doesn't clot off.

You require constant 1 to 1 care of an ACLS-certified specialty trained registered nurse 24 hours a day. And I do mean every moment of the day. There are exactly three nurses on this floor right now who are able to relieve me when I need to go to the bathroom. I eat here, at my computer on wheels. Lucky for me you have no cooties.

This is the type of clinical needs you have. You may be independently wealthy, I don't know. ICU nurses don't come cheap. Let's not even mention the drugs you're receiving. Drugs, narcotics, sedatives I am dumping into your veins like they're on sale. Or even just having a bed here on the unit. Or the three MD groups following your case. That little foley catheter costs fifty bucks.

Every four hours, I draw blood from you (from one of the several tubes), send it to the lab, and based on the results, adjust your medications. I constantly evaluate your heart rhythm and blood pressure, which has a habit of tanking. I keep your mechanical kidney working properly, and I sit here at your bedside because if those fat tubes disconnect for any reason, you can exsanguinate in a matter of 5 seconds unless someone is here to stop it. But don't worry. I have three huge clamps, several emergency meds, an ambu bag, two additional suction tubes all in neat piles in various places in this room in case you need it.

Tonight, I also plan to give you a bath. Your hair's in a braid (well...dreadlock), and I will try to attend to that, too. I can't lower your head to wash your hair or you'll aspirate the tube feeding and potentially pop a lung. But we'll see how creative I can get with the hairwashing. You outweigh me by 75 lbs. And as you went into respiratory failure, you were fighting the nurses and no less than seven RNs (three of them men) had to hold you down so that we could maintain an airway for you. You kept trying to yank everything out. You would have died without that tube. So I'm sorry about the restraints, but they're stayin.

The irony is that you came in with a bellyache to the ED a week ago. What they found is that you have a disease caused by alcohol. It will take months for you to get over this disease. It will be painful. I have never seen a patient with this disease not leave the hospital setting without an Oxycontin addiction that an MD manages with the patient. Be honest with whoever that MD is, by the way. It'll go better.

Your husband asked me if you'd remember "any of this." I assured him, no that, I'm doing everything I can to keep you out of pain and oblivious to this horror we're doing to you. But then he thought about it, and thought maybe he should take a picture to get you to stop drinkin, or at least 'cut down', cos some alcohol is worse than others, right?

No, sir. Alcoholics cannot 'cut down'. There is stop and there is off the wagon, period. She cannot ever drink anything again. And alcohol is alcohol. "But sometimes she only drinks beer." Beer is alcohol. Beer does this. Many alcoholics eventually maintain their alcoholism with Nyquil, sir. It makes no difference.

Patient, since I can't take an actual picture of you, I painted you a word picture.

So you should know, dear patient. Beer did this to you. Beer killed you, except that some doctors and nurses brought you back. To this snapshot.

Your nurse,
/jo

This photo is obviously not my patient. But I see ventilators, CRRT, monitors, an NG tube and some fluids running. The only thing missing are the two triple channels. So, patient? You looked a lot like this.

Go read this:

2008-04-22T20:58:00.001-07:00

The Happy Hospitalist took a picture worth 1000 words.

What I'm sure you canNOT see in that picture is the ventilator, and possibly the CRRT machine and monitors which are probably on the right.

Welcome to ICU in America.

Crazy old bat stole my car keys.

2008-04-12T20:43:00.000-07:00

The other day, some crazy old bat stole my keys. My housekeys, carkeys. Fortunately for me, I have a spare flat carkey in my wallet and my sister's got a copy of my housekeys.

How do I know she stole them? I don't for sure. I can tell you what happened, though.

I know that this crazy woman had to be tied down by yours truly to prevent her from ripping out two fat flank chest tubes, her peripheral iv, and her epidural catheter. She scratched me up. As I tried to get her changed out of her bloody hospital gown and into a clean one, I and my charge RN, Rita had to restrain her from crawlin out of bed naked and screaming. We got the blood cleaned up, the chest tube dressing reinforced, and her body and then eventually her hands tied down so she'd quit yankin on stuff placed for good reason into her body.

I know she tried to take the epidural keys, which I'd set on the bed as I fiddled with changing the epidural med (to something less likely to make her barking mad and paranoid). I noticed and asked, What are you doing? I don't think I listened to the answer, I just took the keys back out of where she was trying to bury them.

My keys were found two days later in the laundry bag. The laundry bags that are changed qshift. The ones that, had the keys been in there originally because I may have accidentally dropped them there, would have been either found on my shift or sent to the facility laundry several days ago, when I actually took care of the patient. But they were found yesterday by housekeeping. In the laundry basket. Nobody knows how they got there, two days after I'd lost them. One of my very kind and considerate colleagues locked them up in her locker.

Crazy ol bat.

I know I'm supposed to feel this well of compassion for this frail elderly woman who is medically complex, and confused, and going through a great deal of mental anguish not to mention that chest tubes HURT. I recall the moments when she said, after begging me to untie her, and me explaining it is not safe for her to do so...."I'm very disappointed in my daughter that she's allowing this to happen to me." It genuinely broke my heart. That frail old woman was absolutely aware that I'd tied her down; she felt shame and humiliation and at that moment, absolutely blamed her daughter for it. And she was disappointed. She was incapable of cognitively reasoning that she cannot pull out the tubes lodged into her chest, because she was utterly convinced that we were trying to kill her. At least, that's what the police officer said when he called the unit to tell us a Mrs. So and So had called 911 on us. (Thank you, Officer, no. Yes. I'll keep the phone out of reach until she's more oriented. Sorry to trouble you, thank you. Yes, good night.)

(I said to Carmen, an RN I know with a light heart & humor, "She called the cops on us." "Cool! Did they come?" It got me to giggle after all the blood and paranoia and stupid sturm and drang.)

And it's her daughter's fault, and she was very disappointed.

I'd been on the phone with same daughter many, many times that night to update her on her mother's condition, and the daughter explained the family history of dementia and odd bursts of paranoia, and how this happened on her mother's previous surgery. I could hear the daughter wring her hands, and ask what she should do, should she come down there? Would that help her?

I reassured the daughter that her mother appeared to be suffering from some confusion related to the recent anesthesia. How it would be easier on both of them for the mother to be angry at me. How there's nothing to be done but keep her mother from hurting herself and wait for it to clear. How the physicians were all aware of what was happening, and their plan was simply to wait and let it clear. How she should try and rest and come in the next morning.

And the mother, I'm sure, shot some stinging accusation at her daughter the next morning. Stinging words she thinks she means right now, and the daughter will really feel. I feel awful for them both because of that.

I know all these things. And I did feel genuine compassion at the time.

Then I realized the old bitch stole my keys.

Is it okay to be annoyed?

I loved this:

2008-04-12T20:38:00.000-07:00

From Head Nurse.

I updated my resume tonight to toss it in the pile to be considered for the weekend option. The differential is roughly 40% of my base. I hear I don't have to be "oriented to hearts" yet, either.

("Oriented to hearts" is something of a sensible gatekeeping thing to prevent newer ICU people from getting a patient they cannot handle, with a mixture of bullshit mother-hen pecking order alpha-queen-bee-old-nurse doctor-coddling thing on my unit.) (Some other time, maybe I'll post about it.)

So. I'm tossing my resume in. I know there are others in the pile already, and the due date is 4/15. Shall see what happens.

Updating your resume tends to get you thinking hard about how much or little you love your job. Which is it for me?

Um. Five...?

Head Nurse's words were good to hear. My answer to whether or not my job is still 5. But now, I'm thinkin this is an okay answer today. Tomorrow might be a resounding yes, love my job.

Today, I don't have my car keys back in my hot little hands yet. (See post above.) So today's probably not the best day to cast a vote. I liked Head Nurse's words.

I am contagion. I called in to work. I feel no guilt.

2008-04-06T16:58:00.000-07:00

I cluster my workdays together, so I had a stretch off. Took a few days in Moab with a girlfriend, and her best friend from Germany (now, my new friend) and the dog, Miko. Our friend from Deutschland caught something on the flight over and was flu-y for four days. We came home a day early.

Then I got it. Hacky coughy achy chills. I'd gotten the flu shot, so this was either nasty quick cold or a milder version of the flu.

Calling in Thursday and Friday nights wasn't a problem. Genie was very sympathetic; Katie told me to feel better soon. Saturday's call-in was the problem. I talked to a nurse I like quite a lot, and who I believe is sensible.

I don't REALLY have to give you a rationale as to why an ICU RN should not report to work coughing her head off, spewing viral particles over intubated and immunocompromised patients right?

I mean.

For real. Right?

You're not one of those mad people who believes those little yellow paper masks does the trick, right? Or thinks a person having trouble breathing due to crud in their bronchial tract is gonna keep that thing on for over 13 hours straight right?

On Saturday, I got an icy "Wow. Okay. Talk to you later."

And the hellovit is, I do not feel guilt for calling in. I'm sure they were short Saturday night, because they are ALWAYS SHORT SATURDAY NIGHTS. And if I had come it and brought the spring flu from Deutschland, the whole unit would get it and everybody'd be calling in this week.

I just don't get this thing that nurses do. I grew up in a different field, and when you were sick, you called in. Remorse? What remorse. You sat your butt at home, on your couch or on your bed. You drink orange juice and water and soup. You crawl out of bed once to go to Blockbuster and load up on movies. You nap. Often.

This is what I've done for the past four days. I have gotten maybe an hour of productive quilting in. Made one productive phone call to a bank. Yesterday, I felt better and played a video game, which I haven't done since October of last year. (Quite possibly the last time I was home sick with a cold.)

Tomorrow I go back to work. The chills and aches are gone, the coughing is better by a large margin and no sneezing. Aren't my patients gonna be glad I didn't slime them with my virus?

I just don't feel the guilt. I don't get why we have a culture that seems so badly to want to require it.

Um....I'm here for a paycheck. I like to help people, yes. But, uh....I'm a lazy buddhist and there are no great martyrs among lazy people, and the handful of Buddhist martyrs had something really important to say that had nothing to do with flu symptoms.

*scratching head*

None of our doctors seem to want to own my patients at night

2008-03-04T06:57:00.000-08:00

So once upon a time, in my ICU, we did not have intensivists 24/7. Day before yesterday, as a matter of fact. We'd spent two years begging, pleading, petitioning for them.

This is the way it used to be:

Several weeks ago, I had a patient whose breathing was deteriorating, as was her mental status. She went from 2L nasal cannula to 15L nonrebreather in a matter of four hours. I called for a chest xray that I did not get an order for first (because, duh). Dr. D happened to be in house late and this individual is nobody's favorite doc. Magnanimously, he addressed the unit, "Is there anything I can do for you before I go home?"

"Yes." I said. "You can look at my patient who's not breathing and I'm thinkin we'll be intubating very soon." He pokes his head in to see the patient. He looks at the chest Xray. "Well, look, she's improving," he says.

I look at the chest Xray. (Insert that cartoon head-shaking noise here...that yadayadayada noise.) Now, I'm not a Medical Doctor, and I do not have your salary or swagger, but when I look at chest Xray A from yesterday and it shows mostly black lungs, and chest Xray B from now and it shows mostly white lungs....THIS IS BAD. When the patient's O2 needs go up by 750%...THIS IS BAD. When a patient's work of breathing increases and the patient feels short of breath...THIS IS BAD.

"Oh no, she's getting better." I am so struck stupid by this beyond-stupid stupid stupidity I don't know what to say. I have no poker face, and I'm sure my expression is a mixture of genuine bafflement and creeping horror. "You don't agree...." he says. Insightful, that one. "No," I say, pinching off the snappy one-liners, "Not even a little bit. She will be intubated before noon." He shrugs, "Well... Not by me. She's getting better."

No.

Not by him.

But she was intubated before noon by a competent doctor who knows that 750% is A BIG number.

Not only did she not get better, she was formally diagnosed with ARDS, spent two weeks on the vent, extubated, reintubated and died this past weekend.

I admitted a eighty-something year old lady who was 90 lbs soaking wet....she had two peripheral IVs in her hands. In one IV, an MD had ordered me to infuse vancomycin. In the other, I was to give Levophed. "But Dr. So-N-So, don't you want to come upstairs and put in a central line? Or call someone to do it for you?" He was busy seeing other patients. I get that he's busy. So am I. I don't want to shred my patient's veins and if he's overloaded, ask for help. I can even get it for you. It's about best practice for the patient, and you know what I'm asking for is the right way to do it. Your hands are tied? Cool. I can find somebody who can do it.

Instead, ego got in the way and he gave me an order to specifically call nobody else. Which is just silly.

Because when you told the nurse of 25 years down the hall that you weren't gonna come look at her active GI bleed, that you were too busy, that you weren't worried right now about her dropping hematocrit, that she didn't need a central line for the pressors she was starting to require secondary to her active bleed or the NG tube right now, and that she shouldn't "bother" the other docs...? She got the charge nurse to call the medical director, your boss.

As a side effect, I also got my central line for my patient before change of shift was out. Kinda that MD, the medical director and the PharmD were kinda on my side on the centrally-given Levophed issue. No reason to give it peripherally if there are MD hands available to do it right. The medical director was at the nursing station at 0400. She earned some big points from me that night by doing so, as did the doc who came in to place my line....the guy I wanted to call to begin with.

Night shift does have a favorite doc, and we want him to own all our patients. The problem is, he's just one guy, and he deserves more time away from the hospital than he tends to take. He takes ownership of patients, and he is thorough and reasonable. We know what good care looks like. Our CV surgeons can be very unprofessional in tone and manner to us, but they completely own their patients' care. They never let you wonder who's driving, or if anybody IS driving. Nobody feels like their heart patient is being ignored, or that stuff falls through the cracks.

Which is what we feel sometimes happens with every patient who isn't under the direct care of one of those handful of good docs we work with. Particularly, this seems to be a nighttime problem.

So we got our intensivists that many nurses I respect fought so hard for. A year of documentation proved that the nurses were right: patients were often receiving inferior care at night because of a lack of in-house MDs. I don't think there's a doc or a nurse out there that thinks having no MD in an ICU for 12 hours is a good thing.

It's not just for the patient who suddenly develops respiratory distress and who only has one side of her chest moving when she's gasping for air. Though that happens.

It's also that nurses hate that feeling of watching a patient carefully, and seeing subtle signs that Bad Things Are About To Happen and no one single thing, or possibly even all things are "callworthy." Here we got MDs right there, so we can say, "Hey, are you seein this trend, too? Can we do something to avert the train wreck that's probably coming?" Maybe even avert it so that dayshift people don't have a daily crisis at 0900 from stuff that could've been handled all night.

Last week, I had a patient with a bp of 240/114 and I paged one of the intensivists who was at our sister hospital. He was a good MD, awake, and followed my patient with me as we tried every foogin drug we could think of (patient had no kidneys), until high-dose Labetolol drip finally worked at about 0700. I went into RN report feeling like I had done my best for this patient. I think the patient felt like I was working very hard for him, too, and that's a good feeling. I felt good, for a change, that I'd worked well with this doc, who I hadn't met before. That he was sharp, and thorough, and he was listening carefully to what I was telling him about this patient's condition.

The intensivist coming on shift for the day tore my head off for not paging the nephrologist first. Do you know why I didn't page the nephrologist? It isn't fair, but this is true: I've worked in that hospital for 2 years. This doc had been paged on dayshift FIVE TIMES and failed to call back...IN DAYLIGHT....same guy you want me to call, now sound asleep? You got two tools in your toolbox. One you've used before and it hasn't worked well for you before, it didn't work well at all today...and there's this other tool, a smart guy, professional to work with, who's awake at your sister hospital and returns pages quickly and is responsive to your patient's needs?

Again. Your patient's blood pressure is 240/114.

Which tool in your toolbox do you grab? It's not a tough choice.

The daytime doc TORE my head off. I stood my ground. "Your partner was extremely helpful to me. He helped my patient. I thought that since this patient is in the ICU, I can call you or your partners on any one of them with critical changes. Patient's blood pressure was dangerously high and your partner handled it." Daytime doc stomped off.

I don't get it: You round on my patient, who's in the ICU, you guys "own" the ICU....but not this patient? Have you seen a worse blood pressure today? The nephrologist was ignoring the sbp of 185 earlier today (which he might consider clinically okay with no kidney, but if so, why write for 20mg of Hydralazine for sbp > 160 when it is completely ineffective and has been all day?), and treating the intractable nausea with 12.5mg Phenegran...do you seriously think these are orders from an MD who feels ownership of this man's care?

I just want somebody to fix my patient. Don't get mad at me for doing my job. If I'm stepping on toes, it's cos I'm not gettin what I need. I mean no disrespect, but I don't care about your toes any more than you care about mine. This is about THE PATIENT, remember?

I get that the intensivists want to be there for support, not to fix every single patient's issue that a medical doc can fix. I don't think the doc that tore my head off was truly angry at me. (And his progress note, written after I left, strongly suggested who and what at whom he was angry...) I think they're just overloaded because, well, they are fixing everybody. Everybody who isn't a patient of night shift's favorite MD or one of the CV surgeons' patients.

I just don't know what to tell ya about that one.

The intensivists being here were supposed to fix this problem of ours.

More soon on how that's going.

2008-02-10T22:40:00.001-08:00

Know what I wonder whenever we get an overdose into the ICU?

Why today?

I always wonder that. Usually they're too somnolent/unconscious/intubated or bleeding out from fulminant liver failure to tell me.

But I always wonder what it was about...T O D A Y.

February 10, 2008 was a special day for this person. They picked today to try and die.

I wonder why.

Our happy health care system.

2008-01-10T05:18:00.001-08:00

Not like this is news to any nurse working/living in the United States, but: here.

What the sick role should be

2007-12-20T23:29:00.000-08:00

Back in sociology, we learned about 'the sick role'. You know what that is. It's when you wake up for work and you feel like hell. You maybe roll out of bed, and maybe you make it to the shower and maybe you throw up and maybe you take your own temperature or just see yourself in the mirror. You hem. You haw. You sound pathetic. You feel pathetic.

You might be lucky enough to be able to do something like call in to work (or you might be a single parent, who has to soldier on, regardless). If you're anything like me, you may feel utterly like hell, but you also feel a relief, too. Because today you get to lay on the couch and drink juice and maybe quilt (your mileage may vary here), but mostly doze off and on with Buffy the Vampire Slayer episodes (mileage varying again here) back to back.

Because you're sick and the sick person's job is to do sick person things.

Like nap. And slurp hot soup. And drink juice. And water. And pop a few ibuprofen. And nap more. Maybe you are lucky enough to have a significant other who will fetch juice for you from the grocery store. And tissues. And will maybe even feel sorry for you.

The sick role carries over into the hospital, too.

I have one patient tonight. She's complicated. A back surgery that was doing very well until it suddenly went horribly, horribly wrong with some virulent microbial and fungal infections in three different places in her body. She's sick. She is very, very sick.

I feel great about the care I've given this patient for the past three days. I spent the first night chasing her hypertension and tachycardia and trying to do so with nipride instead of sockin it to her with the propofol. Night two was preoccupied with neuro issues and tracking down what grew where in which petri dish. Tonight began differently, though. Talked with her neurosurgeon, got some tests ordered for the morning. Other than that, she's doing WELL. Which is fabulous.

I had time to do the royal treatment tonight. Not just a bath, but a shampoo and full fluff and buff with lotion and baby powder and range of motion with leg and foot massage. The whole nine yards. I do not get time for this often, and it was nice. Cos you know? I am a huge proponent of nursing being all about the pathophys and critical thinking skills. But you know? I actually just like taking care of people, too.

And then there's the patient up the hall (not mine, thank god). This patient has lived here for roughly six months in the past year, bouncing in and out as frequent fliers do. She can walk and talk and is hemodynamically stable and has 2 piddly litres of oxygen via nasal cannula. If you have your ABCs (airway, breathing, circulation), you don't need to be in the ICU. Someone made this point to me the other day, and it is true.

But certain physicians here are allowed to admit to the ICU for patients who have nothing more complex than a hangnail. So Whatsername's back.

And she LOVES the sick role.

We do take care of this patient; it's why she comes here. Not just handling her Medical Issue du Jour (which hasn't been critical for five months). We do wipe her butt for her. We do dress her. We do bring her food and drink and all her medications on time. We take her shoes off for her. We give her a walker and a commode chair and dump her poo when she's done. We walk her with a walker around the unit, but do not force the 6 feet to a flushing toilet. We listen to her bray "Help! Help!" every half hour or so. We hear the call light every fifteen minutes or less.

Sometimes when you walk in to answer the call light, she wants you to scratch her back. If you're male, she will ask you to scratch her butt. (She has enough fine motor dexterity to write, for example, but butt-scratching is beyond her abilities.) Sometimes it's cos her legs hurt. No matter how much pain medicine you give. Sometimes she simply forgets why she calls you.

I consider the several hours with my patient as time well spent. I can't stand dealing with Whatsername down the hall. I hate being in that room. I don't mind helping the other nurse in the slightest, that's not it.

It's the bleating and the sense that this person really WANTS to sound pathetic.

Plaintative.

Bleating.

Demanding and thankless.

Even though my unconscious patient won't have any idea what I did or who I am. I won't get a thank you from her, nor do I expect or wish for one. Her family won't thank me for what I've done for her, either, because it's 0300 and they're asleep and have no idea how often I'm in my patient's room or how carefully I am watching her condition and making small little changes to her drugs or changing dressings or measuring chest tube ooze or all the stuff I futz over. I don't even care.

What's maddening to me is that loving the sick role thing. And.

ISN'T THAT STUPID?

Let's assume that I buy the idea that it is sensible and sane to approach people, life, everything as what it IS as opposed to what I want it to be or decide that it should be. This is JustCallMeJo, the lazy buddhist speaking here, yes, but isn't that a rational idea? I mean. We don't have what we want, we want what we can't have and we don't want what we do have. That's what we humans are, right?

Doesn't it seem like an interesting idea to try and live with the idea, just for awhile, that maybe approach things with fewer expectations of what should be....and try to look, really LOOK and accept what is? It's a good idea, I think.

I am finding that this is very, very, very hard. But I'm trying.

But why shower the fuss and the chart-reading and detailed critical thinking skills and slather on the lotion and the foot massages on the patient who has NO IDEA what I'm doing for her....and I get annoyed with bleating Miss Itchy Butt? What difference does it make to me that one loves the sick role and the other is getting a constant infusion of Milk of Amnesia?

It's not just me. I am one of several nurses who walk out of Itchy Butt's room with expletives on the tongue. We talk about it. Why is it that she hits a nerve?

Isn't that ...just.....odd?

Boring hospital politics, part 17

2007-10-27T15:59:00.000-07:00

There is a return to the SuckySoftware drama and the CNO. My availability was requested of me by the CNO last week because she'd like to meet with me for a half hour to discuss SuckySoftware. This meeting hasn't been scheduled yet, but I bumped into her one day last week and she cheerfully asked me about my vacation, wants to meet with me and "thinks I'm very bright."

You'd think that should be flattering, but all it did was put me on my guard and thickened my walls. She wants something; I just don't know what it is yet. I respect her. She's an exceptionally smart and classy woman, has been published and is very active not only in the community, but the state. I would like to trust her, and ....the truth is I don't. I cannot put my finger on why this is.

I can't decide what I think about this yet.

And. What's so weird to me is that....

I mean. WHO CARES? Who the fsck am I, anyway? Nobody.

Why does this shit happen to me, and happen to me all the time, and seemingly when I put so little effort into stirring things up? I don't do this on purpose; or at least, I don't think I do.

There's something else. MyInstructor is very careful during CCclass to ...she will critize something genuinely stupid about SuckySoftware, and will be right about the software being wrong. But she will backpedal and be careful to say, "I'm not against computer charting and I am confident the subcommittees are working on it."

Lots of furtive looks my direction. Either to read my face or because she's afraid somebody's gonna "tell on her", I can't decide. Why would I "tell on her" for saying shit I agree with? Why would I hang her out to dry for telling the truth? Why would I "tell on her" to someone I don't respect (meaning Director)? And what is this sense of paranoia all about? Are we not professionals?

...The other thing wrong with MyInstructor's statement is that R tells me yesterday that the subcommittees are stalled. The only movement we got on positive changes was days after my email went out. Nothing has happened since. I could see the steam coming from R's ears the other day as she told me this. I think she wants my help again to get things moving, but we couldn't talk freely.

(And why can't we talk about this stuff freely? What is the big fscking deal?)

MyInstructor says, "It's so difficult to get everybody in HospitalSystem to sign off on changes, that it takes a LOT to get changes done. I mean it's mindboggling how complicated that is" Except that that is wrong, and we are the beta test site, and the rollout is incomplete across the system. Now is our best opportunity.

Why is this such a charged thing? The software is shit and we need to fix it. Where's the fscking controversy in that? Nurses! They are so unlike people in the rest of the American working world. Why are we more concerned about hugging and kumbaya to nebulous Powers That Be (and who ARE these people? and can I sit them down and talk to them like reasonable people?) than in being effective at treating our patients?

I feel like I'm in China in the 1960s. A lot of people seem to be waving little red books, and I don't know who is doing so only to avoid being dragged into a stupid meeting so that a very small person can fume and try to intimidate them...and who isn't. And I've got a meeting with Mao sometime next week. Cos Mao thinks I'm very bright.

Is that terrible for me to say? Probably not. But it's possibly terrible of me to post on a blog.

Work politics. Boring. I'm not actually a socialist or social democrat, I'm a libertarian.

Know what that means?

Time to go be a consultant again is what that means. I am working on some things up my sleeve in that area. I'm not stupid and I'm not tied forever to whether or not MyHospital ultimately resolves its SuckySoftware drama. I will do what I can to help; I will do my best to help.

But at the end of the day, SuckySoftware will remain sucky. Hopefully not as sucky, but it will be sucky. There are stellar individuals and I'm lucky to know many within my hospital. But organizations and the faceless mass of people within them are mediocre. The only constant among all large organizations is mediocrity.

I'm not leaving MyHospital; I have things to do here. Chief among them is actually learning ICU and building my skills. I also meant what I said that Director is not on my Christmas list, and if I need to step on her toes again to help improve things for nurses who do have my back....I will step on them with enthusiasm that didn't exist before she tried to smack me around.

We'll see what happens I guess.

Right now, I have about three hours to come up with a Halloween costume.

Critical care class, weeks 1 & 2

2007-10-27T14:33:00.000-07:00

This summer my world was all about the social life. It's fall again, and focus is back on work. Quite a lot goin on at the moment.

Critical care class is going fine. I'm with six others: an pediatric OR RN with 5 yrs experience there, an oncology RN (brand new OCN) with eight? years experience, a med-surg RN with two years behind her, an ortho RN with 8 years ortho/med-surg behind him, and two new grads.

Love hemodynamics. LOVE IT. It's new stuff to me, and I'm getting it and my brain is actually working again! Love it! Twelve lead stuff, too...it's not new, but my understanding of it's always been superficial. I'm getting some more depth to that, and that's fun, too. There's a lot to 12lead, so I'm looking forward to taking the class proper. This is the good stuff about CCclass.

However. Because we have to start as if everybody's a new grad, I'm bored half the time. I've had so many people tell me how ass-kicking this class is....and I really shouldn't be this cocky halfway through. I'm just used to measuring troponins and know the heparin nomogram, and know what adventitious heart sounds are. That kind of stuff.

I'm not always at the top of my game. Doing the drip calculations my instructor's way caused me great pain. She uses something she calls "a magic number" to calculate drip rates and she is unable to do the calculations the long way. The ortho RN and I both needed it proved to us, so we put our heads together and over a period of two hours, figured out why the shortcut works. Others in the class just accepted the shortcut and were okay saying that they use a "magic number" to calculate a lifesaving drug drip factor for a critically ill patient. My father is an engineer. Math is NOT MAGIC.

I'm anticipating that once we're out of cardiac and into other body systems, I'll be working harder. There is SO MUCH that I don't know about ICU nursing, and my critical care class should be harder on me than it is so far. In a real ICU, I would get my ass handed to me and I know it. I'm a little nervous that I'm not worrying yet in this class. Again, maybe I'm being cocky and on the exam, I will get my ass handed to me.

But certain comments my instructor makes give me pause. Me, "Instructorperson, will we be going through the clotting cascade and stuff when we do livers? I don't know a lot of that stuff." "Yes, we'll be going through that when we do DIC. Probably not deeply enough for you, but we will be going through it." And what is that supposed to mean "not enough for me"? I'm sorry, am I bugging you?

Possibilities on the Horizon

2007-10-20T14:31:00.000-07:00

So I'm out drinking with one of my girlfriends (another ICU RN) last night & she tosses out a very interesting idea:

Why don't we travel together for 6months or so in Europe? Apparently, there is a need for non-military RNs through some non-military companies to work on American bases in Europe. (This is important since she speaks three languages fluently and I speak one and confidently mangle two.) They pay to move you. Her dog could come, my cats could come. They'd even move your car (though in American standards, my car is small and practical and is the size of a Cadillac by European standards.) We'd have our own spaces, but we'd have each other in a country where neither of us might speak the langauge, plan our schedules to make some three or four day weekends and we'd invest in Eurail passes. And during the week, wall to wall grateful American servicemen. Two single ICU nurses in Europe with no cost of living, and still making a good salary with no taxes.

In what way does this not sound like a riDICulously fantastic adventure?

The only snag I see is vehicle and the fact that the Euro is so much stronger.

It's a thing to think about. It's a thing to seriously think about.

I am fighting the great fight on my unit; I really am. I care about those people...the ones I work beside, mind you. (Not necessarily those I work FOR.)

But this hasn't been the world for working in the same place to get that fancy watch after 50 years of service for a long time. And my career has been full of winging it and bouncing through different contracts and having adventures. I have been to Toad Suck, Arkansas and Surfer's Paradise, Australia. Toronto to Tijuana. That is what I'd done, what I'd made for myself.

I can do it again.

It requires some plotting, several months of it. I plan to embark upon this plotting, oh, today.

Pissing Off the Management: a novella

2007-09-06T09:46:00.001-07:00

Here I go again.

Okay, so my hospital has this new computer system that sucks, right? I know sucky software when I see it. It makes my jaw clench every single time I can't get something for a patient or hear about some Actionable Occurrence because of this POS software. I often think about things like which database protocol they'd probably need to get the Pyxis (or the med-dispensing system) to talk to the system that tells me which meds the patient should receive. Yes. Those systems are different at MyHospital. Can you say Recipie for er...Actionable Occurrences?

Yeah.

Do not get me started.

I'm not alone in this, of course. All the nurses around me are screeching at various volumes about the same thing. Patients are getting the shaft. Not only are there a lot of mistakes, their nurses are spending so much time charting or hunting down and correcting mistakes, that bedside time is seriously suffering.

Some elements in the hospital have handled us in a patronizing fashion: "it's a learning curve". Pat, pat, oh, honey, you'll just learn to love it. Your brain is just slower than my fine MBA mind.

So I tried to use my NPC way back in July to see how it's going on the units. I was kinda shot down, saying that the topic belongs in other committees. Practice Council is not the place to discuss how SuckySoftware is interfering with my practice. (Actually, what I was told, "We're not here to ride the SuckySoftware hobby horse." I don't know why that statement makes me giggle.)

Fine.

Time goes by and the sentinal event doesn't happen, but many bad things do. Some of the nurses decide to get rowdy and start going to meetings to which they were not originally invited. I love this. You'd think I was a Bolshevik at heart instead of a libertarian. They're mad, and they want changes to the software that make it workable for our patients and for us. They're right to want this.

The news from these rabble-rousing nurses (C, A and R) is that they're not getting far in these meetings. Frankly, it sounds like much of what they're getting is the runaround. Many/most other RNs at the table haven't touched a patient in years. Or they Direct an 8 bed unit at another hospital. We have 37 beds. We have some very sick patients, but one of our sister hospitals that goes live with SuckySoftware in a few weeks has a LOT of very sick patients. C tells me they can't get a geek at the table to talk through the problems.

I decide to show some support. I have a legitimate avenue wherein I can yank the CNO's ear through Practic Council, so why not?" So I send an email. A big one. To tell my fellow reps what's goin on in ICU, to get the word out. Communication in power. Numbers are power. Nothing pisses a nurse off more than seeing his or her patients get the short end. Stirring the pot keeps the eyes of everybody who can make decisions on the problem, our problem, our patients' problems.

The email went to NPC reps, to the CNO, to our Magnet Champion, to Quality Control (all of them sit at the NPC table). I copied C, A, R, and M (the rabble rousers), G (my partner in crime on NPC...she's the quieter partner :D ), my boss and Director.

You woulda thought it was WWF Smackdown Email.

I didn't think it was all that bad. Of course, I've been wrong before.

Some patient safety issues:
In the ICU, it is critical that we have access to the full patient "story", which can take hours of searching to obtain in SuckySoftware...does not give a complete story, and certainly not in the timeframe we require that story. We do not feel we know our patients, and as a result we don't feel like we are giving adequate care, much less the care we want to give. We think this system flaw is fertile ground for lawsuits.
One of the most simple examples of this is that meds given in cath lab aren't carried over. Patient comes in with chest pain to the ER, and nowhere will it show that this patient received aspirin, nitro and dilaudid. Not only are we concerned for the patient, we are concerned for our licenses. I believe that this is within our Core Measures initiative, yes? The one that ties real dollars to this hospital?

We also have a problem with a $SpecificDollarAmount system that requires that we use handwritten pieces of paper to obtain certain medications. We had a patient last week develop sudden rapid atrial fibrillation and stay in this dysrythmia for NINETY MINUTES because we had to wait for pharmacy for the physician-ordered IV Digoxin. The process is to hand-write a piece of paper, tube it to pharmacy in order to obtain the med. We do NOT fault pharmacy for what is a serious flaw in SuckySoftware.

Patients are receiving extra doses of medication that should have been discontinued.

And I go on.

Cos I have a tendency to do that.

I got a call from my boss at 8a.m. Her boss, Director, called the meeting for 2pm the next day, which is a great time of day for the night shift. C is called to this meeting, too.

I have some nurses read this email because I'm feeling badly at first, and Director is calling it "negative" and saying it has "gross misperceptions". Maybe I overstepped. My words have been known to be sharp before. The other nurses tell me that they think the email is 'truthful'. Is it negative? They tell me it's negative only in the sense that I'm describing the problem, which is by definition, negative. I reread the email many times.

What I come to is that there's nothing I said that I do not mean. What I come to is that I make no demands, that I'm communicating information I believe to be true to other nurses who may be in similar situations. What I come to is that the people who I respect most, the ones who are here, and who have my back...agree with me. A few nurses thank me "for sticking up for us". This matters to me. That they support what I've said erases any residual am-I-out-of-line feelings because of an irate director.

I show up for the meeting.

I'm bolstered by one more thing: I see a nurse who'd left MyHosptial weeks ago. I don't know him well, but we get along amiably, and I stop to chat. I tell him my tale of woe, and he laughs. He says he's been called into "the office" several times so far this year for some of his actions, actions that either advocated for nurses or for patients but were inconvenient for management. I laugh. As I turn to go to my meeting, he smiles with crinkled eyes and says, "It's never wrong to get hauled into the office because you were advocating for patient care." I was so grateful for that. Put the swing back in my step.

They started in on me before C arrived. Director said that though I don't know her, she wants me to know she's blunt. I nod. Then she tells me what her kneejerk reaction was to my email, which has expletives and included "who the hell is this person?". I nodded. She took several minutes to get through her list of problems with my email (to each, I nod), how she wishes to correct the gross misrepresentation (to which I continue to look at her, listening), how she wishes to offer her support to train me and any other nurse in the finer points of SuckySoftware (to which I continue to look at her, listening), and how she wishes to address the unit-based NPC (I nod). This woman was mad at me. Really, really, mad at me.

I have been in tougher boardrooms than this. I grow calmer by the minute as the rant continues.

At one point, Director muttered to CNO, "That email's gone everywhere by now! Probably all the way to CEO-Of-Hospital-System." CNO quietly said, "Oh, yeah."

I didn't grin but I really wanted to. So that's it. The thought actually hadn't occurred to me that it go any further than hospital-wide buzz on the units, and into some departments. I'm just a stepdown nurse.

The email offended the people who brought SuckySoftware to MyHospital, because they took my criticisms of the systemic problems personally. I knew that. There might have been some sensitivity to me going to the NPC which could have been construed (inaccurately) as "going over someone's head". But there it was: they think it's gone to the system CEO, and likelier still it's in the inbox of CEO. And gee, that probably looks really bad.

These are not bad people, understand me. I believe that they are good people. They want good care for the patients, too. They just want this done quietly. Their interest is keeping things running smoothly, having good patient care with good profits (that is not a criticsm; I'm a libertarian and a proud capitalist). Nothing about a large software implementation in smooth. They don't know how to do this is all. You're not supposed to have lowly stepdown nurses with a pittance of 20 months experience howling about how the multi-million dollar computer system is preventing her from taking care of her patients adequately, much less opening her up to litigation risk.

Thing is? A bedside nurse typically doesn't give a shit about how it looks to people in suits if s/he can't provide good care for her/his patient. Period. None of us chose this job to make money for hospitals.

C and R arrived later in the meeting, having gotten stuck in another SuckySoftware meeting. They didn't want me to be alone, and I appreciated this. R was unceremoniously tossed out at the door by Director. R had taken patients in a 12 hour shift the night before and couldn't have gotten more than 3 hours of sleep. She did this support the efforts, to support me. She gave me a long look, but bowed out graciously. Certainly with more class than Director's got.

There are a whole lot of nurses on that unit that respect R, and know that she has their backs, too. They'll hear that the Director tossed R out at the door.

Director graciously allowed C to come to the table. The hammer was turned from me to C. Director accused her of spreading misinformation, and C volleyed. Director demanded to know "what else she was telling people" and ranted that the subcommitte "had agreed to take a positive approach", implication being that C is "negative". It was all a load of shit: a combination of that old Florence Nightingale nursey guilt shit (and I don't know why that still works on so many of us), coupled with ad hominem attacks and diversional logical fallacies.

It pissed me off. C was on the defensive, and C had done nothing wrong. C was busting her ass trying to do something good for our unit, and I'd had enough of it. Director started hammering at C for my email having direct quotes from the subcommittee meeting. I cut Director off. I leaned forward and put my finger down on my email, (a gesture that was meant to be aggressive), "These words are MINE. That email was written by me, and signed by me, and sent from my email address. I am quoting no one. These are my thoughts, my words." Oh, I was HOT.

Incidentally, Director could not point to a single thing in the email that was incorrect. Not a single "gross misperception." I asked. Several times.

The purpose of the meeting was the email, right? The funny thing about the whole clusterfuck is that the send button had been pushed. Nothing could have been done about it. The meeting could not have had any useful or practical outcome.

I think Director found the meeting most unsatisfactory. She got to unload on me and C, but we hadn't done a single thing wrong. She and the CNO just don't like what we're saying. I'm not sure what CNO hoped to get out of the meeting, if anything.

Fortunately for C and I, MyHospital is also trying to get Magnet status. So the rampant Bolshevism about bedside nurse advocacy (which I happen to believe in, down to my marrow) may have made those smiles excruciating to perform, but they didn't have much choice but to go with it. Truth be told, these women were once bedside nurses, too. Under the fear of the corporate types above them, they want the best care for patients, too. They know we're right. God's on our side, oooh! aah!

If they were trying to persuade me to "be more positive" about SuckySoftware, they just made it worse. If they wanted an apology, they got: "I'm sorry you took this as a slap to you, but this email isn't about you or CNO or anyone else. This is how many of the staff nurses in ICU/SDU are feeling right now, and I'm communicating that to my practice council as one of ICU's representatives to council." If they wanted me to shrivel, they just got me mad.

You threw a nurse I respect, who came to support me, out of your office.

You verbally railroaded another nurse I respect when she is putting up with your abuse in order to do the right thing.

You were snide and snotty to me. It wasn't even witty snide.

You are more concerned about how SystemCEO perceives what's happening at this hospital than you are about my patient last night, who CRIED IN PAIN FOR TWO HOURS BECAUSE THE FUCKING SYSTEM DOESN'T WORK.

The system is so difficult to use that an MD misinterpreted an I&O tally on a patient, discontinued her chest tubes, and that patient was back in the hospital three days later for a pleural and pericardial effusion. Fifteen hundred cc's were drained from her lung, and 300 cc's from her pericardial sack.

WHY AREN'T YOU FIXING THE SYSTEM FOR MY PATIENT AND HER HUSBAND INSTEAD OF DRAGGING ME AND MY COLLEAGUES INTO MEETINGS IN ORDER TO SLAP US INTO SHUTTING UP?

And you think I was a bee in your bonnet before?

just. wait.

Still have a pulse.

2007-07-28T13:37:00.000-07:00

It's just, you know, summer, and my focus has been mentally AWAY from work instead of ON work.

Promise I'll be back around.

Stupid thought of the day

2007-06-26T04:16:00.000-07:00

People casually use the phrase "courageous fight with cancer". Cancer "battles" are always "courageous".

What if the person was a real wuss about the whole thing?

I guess it all starts somewhere

2007-06-20T21:19:00.000-07:00

I haven't written on Nurse Practice Council (NPC) for awhile, but not because we haven't been doing actual stuff.

Last week's meeting, we continued hammering out bylaws. It's not the Constitution or anything, but we made some actual progress in getting a charter done. Our fearless leader, a small, lovely man with a sprightly giggle, has reported that he's attending other "leadership" councils around the hospital. He says that they're impressed that we have an actual draft of a charter with a purpose and everything.

So okay, maybe we're doing better than a sticker club.

It's kind of fun to be a part of the process. I'm now sort of the lead rep from ICU, because the previous lead stepped down and I am a bit more assertive than the woman she got to replace her.

Are we "Magnet material"? Because of how deeply-ingrained it is that certain physicians run things to their liking, I think not. We are not nurse-driven. (We are not even patient-driven.) We are physician-driven.

But.

On the upside, we might be able to make things a little better here and there, and I'm thinkin that's worth the effort, right?

Roux-en-Y

2007-06-10T04:26:00.001-07:00

I've been taking care of a patient for several weeks (read: months) who had bariatric gastric bypass surgery.

It has been fraught with complications. (Repeat: months of complications)

I'm looking over the American Dietetic Association's recommentations on postop nutrition therapy, and it is no way to live.

Foods to avoid: soft bread, sticky (sweet) rice, all pasta, 'high fat' cheese and melted cheese, peanut butter, strawberries, any berries, raw veggies, salads, nuts, popcorn, cakes, cookies, pies, desserts, corn, butter, any alcohol.

Okay, I know that food is not the only thing worthwhile in this world. There are mountains and deserts and sunrises and sunsets. There are good books and rainy days and quilts. There are holidays and families. There's good music and great art and the Golden Gate Bridge. There's sex. There's Godzilla movies. Not necessarily in this order.

But really, sitting on the Campo in Siena withOUT un quartro of Chianti and bufala mozzarella?

In exchange, you can eat cottage cheese, light yogurt (low sugar), selected skinless boneless fatless meats, beans, bananas, low fat soups if you and soggy cereal. (No, really, cereal must be 'soggy'.)

It's just not a way to live.

Yeah, and?

2007-05-30T11:51:00.000-07:00

So I got my ACLS certification two weeks ago. This means that I can now go along to the codes and rapid responses in MyHospital. Supposed to go to three, then I can be "Team Lead #2" for three, then "Team Lead #1". That's what I was told.

The idea of being "Team Lead" when somebody's dead and I'm supposed to fix it is a little as yet horrifying to me. I know sometime I'll learn and get over this, because I see that other people do and have. I do want to do this. It's part of my job, the most basic part. How I've had the dumb luck to not be present for any codes on my unit these five months is likely just the nature of MyHospital's ICU. We are not a trauma shop.

So a few nights ago, it's 2030, and the chimes ring. I think "yay!", but don't tell anybody that. I know you're secretly perky and happy about chimes only for a very short while in your nursing career. "Rapid Response, room 5432" I tell a few people I'm going...actually, I ask, cos I'm not used to this. Bump into J, the resource nurse, on my way and we're off to room 5432.

A respiratory therapist is already there. I also L, who I know from my old unit, and she is directing everybody and bossing people around. (This is a common pose.) I say hi. She doesn't acknowledge me...she's giving report on the patient: 90something year old woman, DNR, respiratory distress, sats 77%, history of COPD, CHF, CAD, DM, and PME...Pretty Much Everything. L is actually not the patient's nurse, and she's not even on our shift. I roll my eyes because I can.

Sure enough, there's a little old lady in bed breathing badly...with a nasal cannula on (and in her nose). She's tachy, but I don't see a blood pressure on the dynamap. There's one RT so far and the patient's nurse (M) and some other random person, the house supervisor and me and J (resource nurse) all in the room. Heckovit is, what I'm seeing is yeah, not good, but er, not four alarm fire alarm. Maybe only two. Or one and a half. I've had my patients be like this and I've fixed them. Okay. This is not scary or intimidating. (Part of me is a little disappointed. Isn't that awful? Cos the little old lady in bed is having a four alarm fire drill day.)

J does something I didn't expect her to do: she pushes me up to the bedside first. Takes me a split-second to think: Huh?...Oh...Good.

I ask "Can I get a blood pressure?" Nurse M tells me the dynamap isn't working right. I don't actually glare at her for that, yay for me. Her thinking returns, and she gets a manual pressure while I lung-listen and I hear: (drumroll please)

COPD lungs.

I ask: "When did she get the MedicationName last?" Patient was just like you'd expect for a 90something 80lbs soaking wet COPDer...inspiration but no expiration, fine crackles, dim in the bases. Woman's got no alveoli left. Whaddya think you're gonna hear? This isn't an acute PE, this isn't any acute anything, this is get some oxygen into her mouth and calm the little old lady down. Little extra Os, little roxanol does wonders for the mind and respiratory status for any elderly COPDer. Get the bp down, get the heart rate down, it's fine.

Then C, one of the RTs comes into the room and says, "Guys...I just did a treatment a half hour ago and gave her some MedicationName then." Her gestures are clearly saying, chill, it's all good. She gently pushes a few people aside, and puts a simple mask on the patient. Because, hey, she's mouth-breathing so the nasal cannula is doing er, nothing for her. Good intervention.

J asks me what I heard. I shrug. "COPD lungs." I shrug again, and realize that I shouldn't take a shrugging-duh tone in a rapid response so I report what I heard. J nods. J also appears to be thinking shrug-and-duh of the situation. J asks somebody if they still need ICU, and when we get the go ahead, we go home.

And that was it.

Now, I know that is likely not a typical rapid response. Often times, we hear the chimes for rapid response and five minutes later we hear them again for a COR to the same room. And rapid response is a great system, and I'm sure it averts a lot of awful things. It's there for any nurse who needs extra help. And if I'd been nurse M, with L there, maybe I would want somebody different at my back. At least, a few months ago, I would have been alarmed at my guppy-breathing ninetysomething year old. I'd have at least wanted respiratory there. And C did show up, so it's a good system.

I can do this. This little bit. I would've had the sense to do the next step and put the cannula into the patient's mouth. I would have gotten a mask. Walked away from there feelin pretty okay. I was grateful to J, for putting me at the bedside. Was cool of her, and there's no rule that she has to be cool about anything.

The most fun thing? Coming back to my unit and people asking, "So...did you fix em?" Getting to nod and say: "We fixed em....Well, C fixed em. But yeah. Fixed."

That was cool.

And that's my story. I can handle a 1.5 alarm fire drill. Not too bad.

An Hour in the Life

2007-05-12T22:14:00.000-07:00

or, Crazy Person #982

Written in a darkened patient room:

Again, I am a psych nurse here in stepdown ICU. It's not my favorite thing, but I can do it adequately. At least...better than the day RN, who had to go into the bathroom to cry a few times with this same patient. I'm pretty sure I can make it without crying about it.

Lemme tell you about my night. It has been from the buddhist 'animal' hell. This is the one where you go about your business with continual blinders on your head and see nothing else around you. I don't remember which level of Dante's hell it would be. Whichever level where Mephistopheles shows you the people who are hitting their heads over and over again with a frying pan. And ...you know...where there's random eyeballs lolling about on the floor, staring at you. Maybe some entrails. And it is humid and smells like toes.

(your mileage may vary.)

I'm in my elderly patient's room, sitting in the corner while he is tied down in four-point restraints plus mitts, plus vest. He's adorable, actually. Trouble is, he keeps trying to rid himself of things that annoy him like his foley catheter, his leads, his IVs. He doesn't realize considerable pain and some degree of blood loss will follow if he does these things. When he's calm, I will retry untying him...feet first.

0315 HR 122. Hold on.

0335 HR 124. D#mmit, I just gave him some IVP's which should theoretically fix him and clearly did not. Hate when that happens. Flipped him, washed his face, cooed softly, checked all six of his restraints, taking them off to massage his feet and hands and reapplied them as he went to rip out his foley. He will never know to thank me for tying him up so he doesn't cause himself to pee blood. Nor will his family. They are not here.

0337 HR 127, bp 156/78 when his norm sbp is 110's. Well, scheiss. Let's try something else. Excuse me.

0350 Cool. 180/70 and 122. (That was sarcastic 'cool'.) Just gave the Clonidine. Now we wait. Now we coo and coddle and get that systolic down. When he looks at me... when he looks me in the eye, his whole demeanor changes. He softens and smiles and I'm just this nice girl and he forgets for a moment that I'm the same one who tied him up and he was trying to bite a little while ago.

This is a luxury to be able to write, despite the fact that I'm sitting 2 feet from my patient's bed in the dark, listening to his respirs, having an eyeball on his telemetry monitor to notice the ST c PVCs and watching to see what he's pulling at. He moves constantly. He is worse than a toddler. Because your toddler isn't going to stroke out with a systolic blood pressure of 180. There is really not much risk of ventricular tachycardia in a toddler.

0400 Pardon me. Must recheck bp, and I have to go hold his arm down and talk in my best Taming A Rabid Wildebeast Voice through the entire thing.

0404 169/66. Neat. Improvement. He tells me that there are six pickles in the pickle jar if I want any. I tell him thank you, but I don't like pickles. I don't mention that there's no pickle jar in his room. When I told him there was no kitty in the room earlier, he flipped out.

I am a stepdown nurse, not a psych nurse, so I perhaps should feel guilt over allowing the delusion. I am sure I am supposed to continually reorient the patient to what is real and what is hallucination. Ask me right now if I feel guilt for letting him have his pickle jar.

0406 HR 109...schweet, respirs 21.

0410 It might be safe to restart his fluids now that he's tied down so tight he cannot rip it out again. Well, 'cannot' is optimism because when there is a will there really is typically a way.

0415 Okay, that went well. Maybe we'll try the feet again this hour. Adopting Taming Rabid Wildebeast Voice again....

Welcome to my night. Actually, it's been nothing like this for the past eight hours for the simple fact that I am writing frivolousness just to get this out of my head. Just to remove it. Because I gotta just dump it, get it out.

Psych disorders are horrible. The truly mad are exhausting. Trying to keep them from hurting themselves...I mean, you can't let a little old elderly gentlemen get so bent outta shape with his anxiety that his systolic bp skyrockets. You cannot constantly take his hands away from his various tubing because you cannot be glued to an out of control person for twelve solid hours. It is not physically possible to sit on somebody for 12 hours solid to stop them from hurting themselves.

Well. Maybe it is, but I don't weigh that much.

We manage to keep our toddlers from their wriggles and wanting to touch hot stoves and the pretty ends of sparklers and stick their hands into grocery carts. I'm not saying that's not exhausting, I know it is. (I'm glad I only did it part time.) Usually the toddlers grow up into small people who are able to hold conversations. And they often spell and can learn that baby bumblebee song with you for long drives.

But when our parents get older and nuttier and it's no longer cute, do we know how to do this? I am not seein how we do this well. There's no guarantee that they'll grow out of it. If it's underlying dementia, it only builds to a catatonia (if that's a word) that brings guilty release for everyone.

This man has been awake for 48 hours so far, most of it going from one anxiety-driven hypertensive crisis to the next. I do not know where his adult children are. Maybe this particular brand of psych disorder has a strong enough genetic component that they, too, are lying, shaking, in a puddle of their own crazy.

I don't know.

I'm here for the night. He can't be left alone, even in full restraints.

He pauses every few minutes or so to look at me and smile, and call me sweetheart. I don't know who he thinks I am. But there's pickles in the jar, and a nice kitty running about.

On occasion, I just gotta dump it out. You know?

I got a thank you note!

2007-05-11T22:24:00.000-07:00

whee!

It's so nice to get a thank you note. Totally made my week, which, lemme tellya, started off pretty crappy. This is the first one I've gotten since I started SDU.

She was an ablation and was nice and we talked about heart electricity, and I made drawings on her white board. (All the while I was thinking about the fact that I could do that on some nice Rives BFK in watercolor pencil.) And I didn't do anything special. She was nice. In and out, one night.

(Incidentally, now that my studio's settled, I spent a whole night drawing chordae tendonae in watercolor pencil...when the Rocky Mountain Imperial Empire sees fit to turn a d@mn switch to turn my DSL on at home...I will scan said doodle and post here.)

So. That's my news today.

It is a little purple note with yellow blobbies on it and I'm going to keep it.

whee.

Relocation hiatus

2007-04-17T07:22:00.000-07:00

This woman needs to be shot: This one. Zarathustra referred to it over at Mental Nurse. Zarathustra, incidentally, is not an angel.

I may have said this here already, but the only wings I have are tattooed on.

Sorry for the quiet. I'm packing to move next week, and then I will have a brief internet-free hiatus. Be back when the dust settles.

Travelers.

2007-04-11T07:03:00.000-07:00

MyHospital, like others in its system, decreased traveler pay by $3 an hour and by $500/month for housing.

It is offering $23 - $25/hr base for ICU travelers.

I mean....WOULD YOU?

There is little point in addressing this at NPC, as every hospital in our system in our state is offering same. They want to cover the shortage with the "super float pool" of ICU/ER RNs who cover our system. This sounds like an interesting idea, and we were still short tonight. Do that math.

Colorado can do this because people come here because it's Colorado. So you out-of-towners, stay home. It sucks here. Go away. Did we mention the four feet of snow in 24h blizzard? Go away. You don't want to come. We have....we have. What do we have? We have horrible drivers in ton+ SUVs that are perpetually clean. Stay away. They're like locusts. Those people just can't steer.

Three to one...

2007-04-09T07:16:00.000-07:00

We're running three patients to a nurse in the ICU.

They decreased the rate they want to pay travelers.

Every ICU RN on two nights ago was on an overtime shift.

....

What happens when your regular staff burns out on doing all this overtime on 3:1 ratios? The call-ins are just starting.

...

And at Nurse Practice Council, we spent thousands of dollars for a Magnet Consultant to come tell us we should be doing research and "shared governance" and "peer review."

....

I am just a stepdown nurse. I promised I'd go to this damn meeting next Monday. I think I'm gonna be a real pain in the ass and pull the CNO aside and relay those points to her.

my quarter-inch-long fingernails on a chalkboard

2007-04-04T07:10:00.000-07:00

So I got shift report from a nurse on ONE patient tonight and it took TWENTY minutes.

Straightforward post-op heart.

She wanted to make sure I knew about the order for Carmex.

But didn't mention the order just below it, which was to transfuse some prbc's.

....

I do NOT make this UP, people.

And we are all human and make mistakes. I make stupid mistakes. And inhale, exhale aummanipadmehumaummanipadmehum. Aum mani padme freakin hum.

Benadryl and bed for me.

Worth a click...

2007-03-30T10:00:00.000-07:00

I don't know who this guy is, but I loved this post. Erica at Blissful Entropy bounced me there.

Some planets are aligned against me.

2007-03-30T07:48:00.000-07:00

I don't know which ones. I try to make this blog less personal, but my week was just partially stupid.

Predominantly because bad things happened to my patients.

On Tuesday, my patient's left lung had been gradually filling up with fluid until he wasn't getting enough oxygen even with thirty liters of it blowing into his face. He was transferred back into ICU, less than 24h after he got out of it. Today, he came back to me on 15 liters, satting fine. (I bet it was the whole MD Decision To Move Him Down To A Room Down The Hall To Receive The Extra Lasix that did fixed him up....meow.)

On Wednesday, a patient got phenergran on dayshift for mystery reasons. (i.e. wasn't nauseated) It made him loopy and he wandered out to the nurses station looking for his wife. I took a hold of him because he was pale and diaphoretic and had C go get a wheelchair. He blanked out and needed to be helped into it. A very long twenty seconds later, he came back to us, AOx3. Stroke assessment negative. Is now fine, oriented, and understandably wary of all prn meds.

Tonight, I had a patient complain of some foot pain. He's 87, has not received pain meds of any sort in days as he has said he had no pain. I gave tylenol. My other choice was dilaudid. An hour later, it still hurt. So I could give a nuclear warhead or I could send in a tank, i.e. Restoril 15 for sleep. Yes, a benzo, not a 'painkiller'. An hour and a half later, I hear a crash and he's on the floor, AOx2. Bonked head. Pupils equal, moves all extremeties, abrasions to RLE (shin) and head. Mediastinal incision scant bleeding, which stopped.

...

I had no control over 2 of those things, little control over the last one. For Crappy Thing #3, I coulda given dilaudid 1mg IVP to an almost 90 year old narc-naive kidney-compromised gentleman whose NOC respirs were 12. Or I coulda said, "Stay hurting for 3 more hours." I did do a foot massage, which didn't fully cut it. I had few choices. Calling MDs for medium-strength narcotic of choice for "foot pain" isn't done in SDU.

*****

I'm irritable over Crappy Thing #3 and I'm getting over it by writing it down. It's just same shit, different post. Both in Crappy Thing #2 and #3, I got shoved aside as another nurse jumped in and took over my neuro assessment. They are used to jumping in and doing it after a patient loops out or falls. Great. However, er, so am I. I spent all last year with dementia and strokes. Got crazy and Fall Down Go Boom (fdgb) down pat. I will check for moving body parts and equal strength. I am looking for abrasions and bruises. If you would please move down and let me get to the head of the bed, I will look at his pupils.

It's likely a trust issue and it doesn't matter except when I'm tired and it's happened twice in two days. It's also that I'm really only a pushy person when there's a vacuum. In ICU/SDU, there's no vacuum of strong people. During a crisis of whatever degree, ego is a waste of time. So when somebody steps up and is doing a good job, I just let them. I'm not greedy. It didn't really yank my chain until I realized I was walking out of the room for a bloody flashlight for good neuro-check and saline to wash the scrapes when two RNs who don't know my patient are still at the bedside.

This tendency to not-push-first might have....outcomes....for me, in ICU.

Then, a different RN said, "You have to call the doc, you know." I turned and barked. "Yeah, I KNOW I have to call the doctor and I will DO it when I'm done assessing my patient." (I apologized shortly after for barking at her.)

I didn't bark at either RN who helped my patient and me because they were helping my patient and me and doing their jobs. Am I annoyed at them? Of course not. I am grateful for the fact that I work on a unit where people help each other, and I have people so willing to help me.

I'm not always enjoying being the New Kid. When, with some things, I'm not new. I really can take charge of fdgb just fine.

In retrospect, one thing is making it okay for me to feel like I took a backseat with my patient. So, I didn't feel calm during this episode. I was remembering Mrs. W, who fdwb on Patricia. Patricia, the RN who refused to call the MD, despite my loud protests and patient-worst-case-scenarios and even the license-defense arguments. Mrs. W had a slow SDH and two days later, lost her scintillating, wonderful Bette Davis personality. So my patient fell and I clearly see his face and his pupils and I also see Mrs W and my brain is screaming FSCK! FSCKITY FSCK FSCK!

However. The benzo wore off and my patient got his marbles back. I was taking my leave after another set of vitals and fluff and buff. I shut the lights off. "Jo?" Yeah? "Thank you for everything tonight." No problem. "It really helps that you were calm through that whole thing." (I was calm through that?) I'm glad you felt that way. "It really helped a lot because this whole surgery and everything has been really stressful." I'm sure it has. But everything is gonna be fine, now, okay? I called the doc, and he'll check you out in the morning, get some tests to make sure. Get some sleep now. "Okay. Good night, honey."

Or maybe he was just headbonked.

*******

This is all related to other things from this week. The week was sometimes stupid and some cans of worms got opened. To be continued...

If I ran the world...

2007-03-28T07:11:00.000-07:00

...people wouldn't hurt so much. Don't like pain, generally speaking. I think it's bad. That's my professional opinion.

If I ran the world, surgery wouldn't hurt. Actually, if I ran the world, coronary artery bypass surgery wouldn't be necessary because everybody would eat a lot more broccoli. Less cow, which has cholesterol and higher in fat. My point is that sawing open your sternum and ripping out busted plumbing by replacing it with plumbing elsewhere in your body would be a kinder, gentler process...kinda like in Star Trek where there are whirring lights and funny noises and no blood does brain surgery plus recovery time in 25 seconds. I vote for that.

Smoking? Think that's bad, too. I'm even an ex-smoker, and not one of those rabid ex-smokers who purged themselves and now wishes to purge the world of this evil. When I drink, I want a cigarrette. Or two. And on occasion I just want one, anyway. Even though I think smoking is bad, a thought grounded in mountains of scientific evidence. A sixty pack-year habit? That's bad.

Also, if I ran the world, people wouldn't drink a quart of whiskey per day. Generally against that, too. Think it's not good, just not healthy. If I ran the world, we'd all deal with our realities in much more productive and happy ways.

These are my opinions. Thing is, I do not run the world. I do not make other people's decisions. I do not *want* to make other people's decisions. It would be a debacle if I ran the world...for one, there'd be too few accountants in it. And a lot less math. Um. And beetles! I'd get rid of all beetles, especially box elder bugs I HATE those.

But I'm on board with the idea that math is probably necessary for stuff. Accountants do things that have (dead dull) use. I am not on board that beetles serve any function, as they do not till earth, do not pollinate, do not actually appear to do anything useful in the ecosystem. However, I am not an entymolygist and I could easily be wrong on this point. (And why does anything NEED six legs!?!)

....I had a point.

If he hurts, give him the fscking medication. Do not give one tablet of Vicodin for 10/10 pain ("because he always says 10/10.") Give him fscking Dilaudid. Because when I get to him, his respirs are 32, his face is grimaced and his hands are balled around wads of sheets. How are you seeing, "A tab of Vicodin" here?

The world is not as we fashion it to be. The world is never as we would fashion it to be. It is only what it is. People only are who and what they are, and they come to us who and what they are. Can we quit trying to change them to think as we think, do as we do, and feel as we feel?

He hurts. Your feeeeeeeelings about his pain level and his habits and decisions are a complete nonsequitur. If you feeeeeel like a drug-pusher, fine, vent it in the medroom because we all do it, we all need to do it. But push the fscking med. You don't run this place. Relax, that's a good thing.

The Nurse Practice Sticker Club

2007-03-22T02:05:00.000-07:00

When I was 12, we had clubs. For stuff. Sticker club. Or, dancing club or roller skating club or bike-riding club. We'd take turns being president, and vice-president, secretary and treasurer and everybody got a job. Somebody would take attendance in a spiral notebook with a pink or purple pen. And we would have meetings. I don't remember what happened in these meetings. But we'd have our club for a week, and then we'd have a different club next week and somebody different would be the attendance-taker. I remember lots of meetings on the grass in my back yard. Or Jenny's. Or Melanie's. After while the meetings got held more at Melanie's house, because there were boys in the neighborhood playing basketball. And eventually, we lost interest in clubs.

NPC is having a lot of meetings lately. They're scheduling them for four hours in the middle of the day. Eight p.m. to midnight my time...after having woken at 4 a.m. to do a 12 hour, 7a to 7p for me. NPC wants to organize unit-based practice councils.

The trouble with this is....NPC doesn't do anything yet. It is a sticker club right now, and we listen to a consultant hired to help us attain Magnet status. And we do what she says. She says we need sticker clubs on each unit, so that there's communication between Big Sticker Club (us) and the little sticker clubs.

I ask around on my unit if anybody has opinions about NPC, and nobody does. Because we don't have a function. We don't have bylaws. We do not have action items (other than spawning more clubs). We don't know what we DO.

I joined because at another hospital I worked at, the NPC did stuff. They made charting consistent hospital-wide. They made practices about IV and tubing changes consistent. They do research. They provide continuing ed to the nurses on the units. They bring gripes from the units to the NPC table. Everybody knew who was on NPC. RNs were elected to council and expected to be accountable to their units.

So I inserted myself on NPC in the hopes of doing some of this stuff. I'm finding some frustration. I send suggestions to our council chair. Could we add this to the agenda? Would you like me to take the preliminary steps to do x?

No.

The other ICU rep (a sensible woman and incidentally, the only other NOC shifter at the table) and I were charged with finding more poor slobs who want to go to meetings of ill-defined purpose.

Trade you my extra sparkle roller-skates with hearts sticker for your round unicorn with rainbow sticker.

I am not her big sister....

2007-03-19T09:41:00.000-07:00

I am not her big sister.

I am not her big sister.

Even if I was her big sister, it wouldn't be my place.

Taiwan.

In May, i.e. in six weeks.

Do you know where I can get my shots? Will they take my insurance?

*boggle as I'm doing math in my head and a flood of microbiology comes to mind*

I give her a clinic name. Knew the nurses a little. You, er....
have....some...SOME...shots right?

Tetanus.

That's good for 10 years. How about Hep A?

No.

....I don't even go through the remaining litany. The look shows it, though.

But Fiancee's Brother and Sister-in-Law went without them.

(If you're curious as to what I think of the collective brain power of this family, you can go here. The cliffnotes version is that somehow the laws of natural selection managed to miss them.)

She sees that I'm thinking this, as you can pretty much read everything I think on my face. Oddly, I don't think she sees the memory of when she was in Peru and told me she jumped in a river and golly, had diarrhea for a week. 'Could it be cholera?' 'I don't know, Fiance has given me some antibiotics. Really...? I forget what cholera does....' (Fiance is a pharmacist. Yes, Fiance doesn't have shots, either. Ask me what I think of Fiance.)

I guess my description of cholera wasn't graphic enough.

I am not her big sister. I am not her big sister. I am not her big sister.

Do not tell a crazy ba$tard to "not mess with you because it's not funny."

2007-03-18T07:29:00.000-07:00

Yes, there are patients who will stool themselves if you tell them this.

Yes, it is gross.

No, some people do not have normal shame inherent in successful resolution of Erikson's Initiative v. Guilt, completed by age 6 by most of us with a pulse. Some people really do want to piss you off to prove an inane point more than you think possible.

You'd think I wouldn't have to SAY that to a nurse.

Fortunately, I don't have to. I can gripe about it here, in my happy little outlet. In the real world right now, I'm working on expressing compassion, not on telling the world what's wrong with itself.

Besides, poop kinda speaks for itself.

..........

My patient last night is just completing his volcanic alcohol withdrawal last night. Off the benzo drip. CIWA score almost where the rest of us are on any given bad day. Diminishing number of restraints. 2mg of Benzodiazepene last night, down from 12+ the night before and 7 plus 2 of Antipsychotic on days. I feel good about a night when I didn't just medicate the mentation out of a patient.

He thanked me this morning, which oddly....hurt. I had this man tied down last night, all night, and didn't give him his phone or his car keys like he asked for (you're welcome to anyone driving a car anywhere in the city last night and to everybody in this guy's phone list) and he THANKED me this morning.

just odd.

Sometimes I'm a very analytical clinician. Sometimes, I'm still just empathic me. Right-brained, artsy, intuitive and (ex-)pagan me. Good nurses are empathetic. Few of us call ourselves 'empathic' but a large number of us are. To function, all of us put it aside 90% of the time. Each of us can tell you patient name, diagnosis and the minutest details about that other 10%.

This guy...? He's just some drunk whose life is imploding. He doesn't constitute that 10% for me, even. But the yawning, hungry maw of hell this guy is living in was a little to ...bloody for me to not....notice...ignore...avoid.

Again, I'm reminded that physical suffering is horrible. Awful. I mean, I am mentally revisiting my angst about liver failure if I need proof of it.

Emotional and existential angst, the stuff of the psych nurses....really and truly just as horrible. I looked into those (hubcap sized, I mean) huge pupils just for a split second, but all the fire and screaming and darkness and clawing at slimy walls like the sides of a well from which there is no escape...was in it.

So strange. I really. LOOKED. at this guy. It was suffering the size of Everest, though, and I saw it and he knew I saw it. ...Strangest damn thing.

bloody. howling. sinking. light fading to a pinpoint and shoulders covered in slime from the cold rocks that scrape as he falls...

Meet a patient like that. And I'm just. Wrong about everything some days.

The organized mind.

2007-03-17T06:48:00.000-07:00

I am an absolute snob at certain things. Oil paint. Sesame tofu. Godzilla movies.

I'm also a snob about receiving report at change of shift. I may meander when I write, but when doing patient report at shift change, get to the point. Economy of words. Do not tell me they fell down went boom in 2nd grade. Chief complaint, pertinent history, review of systems, last prns, outstanding issues. Bang. Done.

I would be delighted to socialize in our spare moments. Really. I like the new people. But before we do that, can we get the basic job done first please? If we do it faster, I'll have even more time to ask you about your househunt/husband/children/hobbies/etc.

There are two dayshift RNs who I like very much personally, and I respect. And they drive me wild. Report with them can be like listening to Wagner. (Not every day, but many, and always on day 1.) The Bugs Bunny version of Wagner, mind you. It is a saga that never ends. (Insert swelling music with images of valkryies here....kill the wabbit!...kill the WAAAABBITTT!) For one nurse, there is no thread that I can follow other than "this happened today and this happened today, and oh, this morning this happened, too."

She starts well: "This is a 67 year old gentleman in for a CABG times three, done on the 12th..." and then we talk about how he felt about ambulating the fourth time today.

Don't care. Unless he an epic meltdown about his fourth walk around the nursing station and you had to call a code green.

"He's voiding okay (define "okay"), and I've dumped the urinal 6 times."

Don't care. Just UOP = x mL, please. If it's not clear yellow, you can tell me amber/sediment/hematuria... otherwise, move on.

Do NOT give me seven full minutes on the psychodynamics of this patient and his relationship with his wife and forget to tell me he has a goddamned pacer and AICD. When I start seeing cardiac pauses and pacer spikes at 0130, I am thinking: "Did you LOOK at his strip or were you too wrapped up in kill the WAAAAAABBBITT!"

(Oh, and I am A NIGHT SHIFTER. I care about my patients and I don't give a damn how their appetite was today. You're a day shifter, and you don't give a damn how their sleep was, either. We make each other crazy by thinking the other shift cares about these things. Don't waste my time with ad nauseum about what was left on his plate unless we're into albumin-bolus and TPN/TF territory and... I won't waste your time unless he's a) less than 4h sleep or b) becoming so psychotic you should expect to restrain him.)

Most RNs at my hospital do review of systems, which makes the most sense to me. But if you want to do head to toe (or toe to head), that's okay, too.

Nurses are organized people. Most nurses are scientific people. I find it easy to talk to other RNs about nerdy code things and coding life, I find it very difficult to talk to them about my life as an artist, or my meditation practice, or, come to think of it, anything on the equally-developed intuitive right side of my brain. The exceptions to that rule become actual friends. Generally, these people were good at algebra. How I managed to slip in among them I do not know.

Taking 45 minutes to tell me about 3 patients is pathology. Is the product of a disorganized mind. Is fugue, in both senses of the word.

I would love to tell you that my sitting on my zafu every day has made me a more patient person...and that I sit in equanimity as the clock ticks and my off-going RN travels the stars to glean the occasional pertinent detail about my damnpatientforthenight.....

But if you've guessed that I stand there bug-eyed, teeth-clenching and finally bark questions after we're 11 minutes in and I still don't know whether the patient is in sinus rhythm or not, you would be correct.

It is a personality flaw. This intolerant impatience and unwillingness to let the disorganized mind to keep putting her damn paws on my patients after 1915, givemethatfsckingclipboard!

I know this. I will work on it. Aum mani padme hum. Aum mani padme hum, dammit, aum mani padme hum how the hell did you get to ICU with a brain like thaummanipadme hum. Aum mani padme hum.

Who the heck would sue me when I'm trying to help?

2007-03-10T22:10:00.000-08:00

Check out Angry Medic's story.

I don't know any MDs well. I work nights, and the few that I see tend to be bleary-eyed and wearing clothes they'd donned 22 hours previously. This is unfortunate, as I'm sure a great many of them are worth knowing. (Not all, but probably most. Kind of like most plumbers and accountants are probably worth knowing, too.)

So when I read Angry Medic, I'm sometimes struck with how different the world of learning medicine is different from the world of nursing, and of learning nursing. It shouldn't be, as we're actually in the same world. But if the same situation he describes happened to a pharm class in nursing school, the story would have been very different. I doubt any person present would have been thinking 'lawsuit'. (You probably would have had several think, "Neat! I can practice CPR!")

It's a travesty that so many commenters to AM told him he was right to fear lawsuit. This is awful. These posters can, no doubt, make a solid case for being right to fear lawsuit. And I'll bet you most of them hate the state of a world in which this interrupts good intentions, good help, good care to people. I'm sure most MDs wanted to be MDs because of good intentions to provide service to others.

This fear of lawsuit doesn't exist so much like that in nursing. I certainly know RNs who have been to court, none that have been censured. We are all human, and we've all made mistakes. I've made mistakes. I'd tell you what they were (because I remember each) if this wasn't a blog out on the internet. Nurses who've been on the stand tend to be sticklers with documentation, and I can learn from them. (One charts like Charles Dickens, and I don't want to learn from her, but that's beside the point.)

But fear of a lawsuit wouldn't stop me from helping somebody who falls down, goes boom. Fear of HIV/Hep C or other infectious disease gives me pause. Give me a decent barrier, and I'd be fine. I'd make do with a rag or a shirt in a crisis fine.

Fear of a crazy bastard who bites or will suddenly grab me in a headlock gives me pause. But that only causes me to consider my position when I'm approaching this person, and that takes split seconds. Fear of being hit by projectile vomiting and ruining a shirt and the hours of showering and scrubbing it would require later...same thing.

But 'lawsuit' wouldn't cross my mind in those critical seconds. In the U.S., we have a Good Samaritan law that protects us. (Sad that one is necessary.) Based on the comments AM's gotten, this lawsuit fear seems to be something that a sane MD has to think about in a crisis. Just like my thinking about biting, HIV and projectile vomiting are kneejerk thoughts. 'What if this poor bastard sues?' I had no idea. I find it fascinating.

It also makes me wonder what the hell medical school is *teaching* these basically good people? What are the NHS and the American and Australian hospital systems teaching to people out there trying to give care to their communities?

*gah*

This is messed up.

I get called an angel at least once a week. This week, it was on Thursday. A patient's husband was expressing gratitude, and it was best-intentioned. I thanked him, laughed it off and told him he could ask my mom if I was an angel and she'd give him an earful. (This is one of my ways to get the idea across that nursing is a profession and not a vocation.) Sometimes patients mean this 'angel' thing in a way that is so saccharine or manipualtive it gets on my nerves. I'm not an angel, I'm a clinician. I'm a nice clinician and I like to help people. The only wings I have were tattooed on in a neon-lights parlor on Colfax a few years ago. Tequila was involved.

(Pointless segue: I had a patient last night tell me he will be putting me on his Christmas list. Had to say, that was a first and cute as hell. Ex-IV drug user, ETOH, slowly dying while waiting for an organ to be transplanted. His words are sweet and this is a man who probably has in the back of his mind something a little more airbrushed and Playboy with bows in indecent places, but I didn't actually care. It was still cute.)

Maybe it's this reason that people don't tend to sue nurses. For one, I don't think they know they can. (And I'm not gonna tell.) For another, I think there's that idea about nursing that we're all sweet and cute and female and helpful that actually ends up protecting us. That some of us are men, some of us are fugly and some of us are profoundly ill-tempered and that ALL of us are multidimensional people and flawed, seems to not be the point.

I don't want to be a doc. I'm glad there are good people who want it. I'm sorry for them that they have to hesitate for fear of lawsuit. I hope nursing never gets there.

No.

2007-03-08T07:18:00.000-08:00

I don't get it.

Had a friend almost-crying on my shoulder today. This is perfectly okay; I've offered a shoulder before. She's a good person. She's a good nurse.

She's got some health stuff goin on. Big stuff. Medical leave stuff. It's not new, it's several years that she's been dealing with this stuff. She wants to scale back to two days a week instead of three a week and she needs to do this. It's not up for discussion that she needs to do it. She has stunningly obvious medical reasons that require her to take it easy.

I mean. This is not optional.

She applied for a job at SomeOtherHospital. Got the job, turned the offer down on the promise from her supervisor that "Oh, yeah, we can scale you back to two shifts a week." This morning, said supervisor backpedalled. "Well, that would be part time, and I don't really have a part-time position available."

I hear the tail end of this conversation, and Supervisor goes to office, and Friend looks like she's about to crack, but says nothing. Friend takes me walking, tells me.

My words of advice: "Well. You can say to Supervisor that if she can't make it work, you'll be taking a leave of absence." Friend: "I don't want to threaten." Me: "Who said 'threaten'? You need time off. This isn't a choice for Supervisor to make, this has nothing to do with her. If she can't 'create a part-time position', okay, that's fine. She cannot create a new position for you to be. You can therefore leave for three months and she's required to keep your full-time job open for you. You get your time off. She gets the logical consequence for making an asinine management decision. Meanwhile, you can look for a part-time job for a nurse of your caliber and have a line of people wanting to hire you for two days a week."

Friend wrings hands. Friend is still thinking she's going to "threaten" and nice nurses don't threaten.

No threaten. Do. (Like Yoda says.)

How is this up for discussion?

In what cockamamie universe is this not a JOB, people? With FMLA rights the same as those given to every other working, taxpaying citizen of the United States? And where is it not okay to vote with your feet when you're working for someone unreasonable? When is your health optional? Why should a nurse feel guilty when some person with deplorable management skills is managing-by-taking-advantage-of-you?

I can't say this doesn't happen in the business world because it does. But most not-nurse people know that the sacrifices and the blood and guts these people put out ...are not rewarded. They do not have a saintly home. They have lives of missed soccer games and dance recitals and missed weddings and missed deaths and a whole lot of things that Could Have Been.

This is why I walked away from my $75/hr gig in Tijuana, Mexico, to be with my grandfather when he died. I do not regret it. A woman that was my friend told me at the time, "I don't understand this...I don't know anybody that close to their grandfather....You should have cleared this trip with me first" ("Ask the cancer eating his body alive if it can come back another time, M. Because I'd really it rather not kill him now, either.")

My point of this little anecdote is to point out that I am astonished to see how people cannot fathom that a job is just a job. It isn't your life. It is more than okay to regard it as just a job. It's important to have goals at work, professional goals, but it's not okay to put that first when it's your health, or your family's.

Duh.

According to some book I read, part of this is generational. That a job is just a job. People of Generation X, this doofy tome says, have learned that it's important to balance work and life, and not live to work as previous generations have done.

My friend is older than me. But not so not-my-generation that she doesn't hear me. That she doesn't hear the sense of what I say to her. Just enough older to feel guilty that I might be right. Just enough older that, I'm afraid, she may accept the terms she's been given and let her health get worse.

That guilt is not okay.

No.

It's an easy word. It really is.

You are not a hero for picking up 17 shifts in a row because "they can't find anybody." Guess what? They really won't find anybody if you're willing to be the beast of burden. You will never go down in the history book of What A Fabulous Person because you took it all on yourself. You are not Abandoning Your Patients. You are not a bad nurse for needing to take care of your health.

You became a nurse to help people, and you do.

The world is an endless spiral of suffering that increases exponentially. With each birth, by 2050, there will be 11 billion of us on this planet and each one of them will suffer horribly. Each withers, sickens, debilitates and will die. You do not stand alone to stop the deluge. You are not the arbiter of the cure.

You need to get a grip. What a nurse does is of immense value. But a broken nurse stops the suffering of no one. Even the physicians say to heal thyself. Why don't nurses do that?

No.

Just. No.

Say it with me now.

The big fish in the petri dish

2007-03-04T01:00:00.000-08:00

I picked up an extra shift. After eight weeks of luxuriating in Only Full Time Hours, I decided it was time. They didn't need me tonight on SDU, so I called Rehab and they were a little too happy to have me back on a Saturday night.

So I'm charge on rehab. It is 11:45 p.m. All five of my patients are happy, medicated, sleeping, dressings changed, thoroughly charted, crash cart checked, chores done. I've made sparkling conversation with family members, and reviewed medications for home, and talked about mechanism of action of select laxatives with a bowel-perseverating woman who wants me to call Dr. Franny at 9:00pm on a Saturday night to ask for Metamucil. (Gotta love those people.) I've confirmed NIVA results and altered anticoag orders to return to proper weight/mg.

I can't think of a single thing more to do with these people.

Oh, and T's (the float RN who's with me tonight) six patients? I've bedchecked them and charge-checked her med admin stuff. And met three of her patients cos I'm helping her with her call lights too.

I got my CNA and me some coffee.

I got eight hours left.

Actually it feels good to be here. Really good. I own it. I am bulletproof. Remember me telling you about the nerd who was blinded by my 'mad unix skills'? I'm 'damn' here and I feel it. I forgot how good it is to be in your skin when you own it like that. To rehab, I am now a bigger fish and I walk in and the people here smile and say, "JustCallMeJo! We're so glad to have you back tonight!" And they mean it. They really do. It's kind of neat.

This pond is the size of a petri dish, and I don't care. I'm gonna wallow in my "mad (rehab, anyway) nursing skills" tonight. It's a nice little petit four in my eight weeks of feeling dumb and nervous that I'll screw up horribly...of not knowing everybody well and tripping over invisible rules and general learning-to-fit-in-ness and all that normal stuff that just takes time. I love my new unit. It's becoming home, really enjoy the new people, really love the challenge and that I'm stimulating some neurons. And....the smaller town home is also nice, too.

I am thinking all this, then around 21, the chimes sounded. Code blue (COR 0) in room 8214 (not a room that exists at MyHospital, duh). T and I both hop into the computer to look at 8214. She knew the patient from three days ago when she'd worked on 8west. Chimes again. Code green (out of control person) to the same room. (Person's dead, then they're out of control? ...how does this work?)

So I'm itching to know what happened and missing being on my unit, where I'd get a chance to help and be in the thick of things. It's another liver failure. And hey, recall that I know a few things about that. I am itching and everything is ridiculously under control here...so go downstairs at 2230ish, after the patient's been shipped over. To stepdown side, where there are two SDU RNs, an ICU RN and the tele monitor and that is it.

The first thought goin through my mind (from the moment the chimes rang) is that R and C are havin all the fun. And they are. C's talking about somebody's pacer spikes to the charge nurse, I wave. A's pulling off orders, I wave. J (ICU) is charting, I backscratch. (This is my sign of distracted, idle affection, not something weird.) The place is buzzing, but it's cheerful buzz... meaning whatever happened, it happened well. I poke my head into the patient's room and notice that there's a pulse. Nice. And R's in there, running a 12 lead.

Bastard. :D

He even had a big grin on his face, too. I bet I thought "Bastard" loud enough that he heard it. Thus the grin. I missed out on this one, being in the beyond-the-burbs. ...

They're busy. I go away. Upstairs to the town where I grew up that had a cornfield across the street until I was in high school, when they paved it.

Up where the crickets are chirping.

It's all good. It's a nice little visit. I'm getting paid 68% more tonight just cos it's overtime, a Saturday, and I'm charge.

...chirp, chirp, chirp....

p.s. Something else I'd forgotten about rehab is that a rather large number of nurses here are perimenopausal. It's two freakin degrees in here. I'm in my lavendar polar fleece, two warm blankets, sucking down hot coffee (which I'd be doing anyway), and my fingers are still icicles.

"Someday, you'll grow up and be a dayshifter, too."

2007-03-01T22:57:00.000-08:00

The dayshifter who said this to me today means well. He meant, "I know you're new here, and you seem like you're sharp enough to, once you get used to things, come play with the Big Kids in the daytime."

He means well, but he got a withering look and "I do not want to be a day shift nurse."

Reasons I Do Not Like 12h Day Shift

* Every time you turn around you're feeding people. I felt like a waitress, not an RN.

* Every time I turned around, I'm looking for my clipboard. Unilaterally, it was in the hands of some MD who didn't have the courtesy to tell me who s/he is and what they would like done for my patient. I would find out 2 hours later after I saw the "new orders" printout, and I'd end up wasting my time paging somebody to ask for clarification on it. (Also wasting the MD's, and unit secretary's time, too.)

* Utter chaos. Too many people, too much wailing and gnashing, people pushing others aside in a struggle to make themselves seen, heard, or have their orders put in first. There are no more medical crisis on days than on nights. People crash 24 hours a day.

* This fight for survival leads to a certain unwillingness to pitch in and help others with their own patients. On my unit, teamwork is the rule at night, and sometimes happens on a good day.

* Family members are here by day. This is terrible to list this in the negatives. Large families who love the patient are a positive when the patient feels loved and supported. They are a negative when the patient is in INTENSIVE CARE because they need rest and quiet. They are a negative when the family is dysfunctional and doesn't trust one primary family member to disseminate information and I, the RN, has to go through a complex plan of care and med review for each of say, 5 siblings. If I have to do that for your family, you've taken 2.5 hours away from my ability to care for your loved one. Families are a problem when each family member is asking for pain meds for the patient (patient alone knows their pain level, families tend to want to super-medicate because it shows "love"), or they're trying to feed them a fruit smoothie when they're in diabetic ketoacidosis. Families are great. Except that sometimes they are not. In ICU, they go home in the evenings. :D

Reasons I Like NOCs.

* I read my charts. Dayshift doesn't have time. They're swamped with things like calling the kitchen because, "She said she wanted turkey and you brought her bologna." I'm not suggesting that this is unimportant because maybe bologna gives you hives. And the patient's comfort and well-being is why we are here. I became a nurse to do nursing, and I feel like I get to do that at night. I read my history and physicals on my patients. I read physician notes. I read previous shift nursing notes. I read lab values. I notice trends in vital signs. I have more time to do this than your day shift nurse has. Your night shift nurse might know you and your story WAY better than you think s/he does.

* Nighttime physicians. I tend to love the docs at night. They tend to be polite. They tend to talk to me about what the master plan is for this patient, what tests they want and what they anticipate finding in those tests, why we're switching this med or that. I'm not one of those annoying nurses who wants to be a doctor or wants to tell the doc what to do with the patient. I want to do nursing. Nursing works best when the nurse can put her/his energies in the same place the MD's energies are placed. Don't you think?

* Again, with nighttime physicians. I had a WONDERFUL ED doc in the other night whose specialty was toxicology. Patient with an overdose came in, worsening cardiac issues in an otherwise healthy heart. This MD, after the patient was stabilized, explained to the RNs present certain EKG changes due to the specific drug the patient had OD'ed on. Treatment for these EKG changes would not be what we RNs would expect (atropine), but the MD explained that when we saw these changes again for this clinical picture, a different drug should be given (more propofol). It was great to learn from this doc, who clearly knew this clinical picture exceptionally well. And bonus: was polite, professional, and happy to share her knowledge.

Nighttime docs. Fabulous people.

It's that kind of stuff that makes nights a better place to work. Dayshift does not have time, and I mean both RNs and MDs. Why would you care that a bunch of RNs spent 20 minutes to learn this specialized cardiac pathophys stuff from an ED specialist? Instead of say, fetching your turkey sandwich? You aren't really asking that question, are you? When your kid inhales 60 tablets of an antidepressant, you are gonna be so happy I know how to keep your kid alive.

* I have time to broaden my brain a bit in other ways. It's called professional development, and MDs and attorneys and IT nerds do it. Probably dentists, too, but I don't know any dentists. When I was an IT nerd, I did this and gave it no thought. People seem to think this is somehow not appropriate or necessary for nurses. Not being on dayshift, I'm not there for the frequent procedures that happen during the day. I don't get to yank chest tubes much. Or assist with the odd thoracentesis, or bronch. This is a bummer. But at night, I get to actually look up what a MUGA scan is, instead of take the snatched "it's like an echo," response to the MD who's ordered it and running down the hall.

* The quiet. I am softspoken. I have a big laugh sometimes, but people are otherwise always telling me to speak up. It's not because I'm afraid to speak or mousy. I did not grow up in a house that had shouting (at least until I was a teenager). I grew up in a house that turned the tv down or off when someone was talking. I like pauses in storytelling in which one thinks and rolls words around in one's head. There are daytime nurses who are like this, too, and they've learned to be more aggressive to get their patient's needs met. I don't want to learn this aggression.

There are other things true of night shift. Nights does draw certain...personalities, or proclivities.

* We tend to have a rated-R sense of humor at night. Days keeps it PG-13. There's good and bad with this. If nights seems less professional than days, this is why. If I feel like I know nightshifters better, this is why. Only the NC-17ers work at night. They're rare, and they stick out, and there is no way you'd find them in sunlight.

* A lot of normal people work at night. Mostly, that's what we have. But often, the oddballs are found less on dayshift.

Yeah, I miss sunlight. I try to stagger shifts so that I can see it sometimes. Yeah, it's a major ordeal to get a dentist appointment. There are entire weeks where sleep is optional and entire weeks where my life is built around sleeptimes. Denver is not a 24h town, and this sucks.

But there's a 24 hour diner not far off. And four o'clock in the morning is an underrated time of day, good for being awake and driving up to a state park to look at stars on a random Tuesday. And for this brief time left where I have a roommate who wanted cable, all the really great (horrible) science fiction movies and old Star Trek are on at 0300ish. Night of the Lepus. Invasion of the Body Snatchers. Starship Troopers. You know the ones. I consider this a bonus. Your mileage may vary there.

Nope. You couldn't get me on days for all the coffee in Columbia.

Change of Shift is up!

2007-02-22T13:12:00.001-08:00

(Time flies!) Over at Protect the Airway! See you there (okay, once I'm back down from the mountains I'll see you there...)

Things I cannot live without:

2007-02-21T22:06:00.000-08:00

ApgaRN tagged me for a meme It started here, with someone named Shane, who I have not had the opportunity to meet yet, but shall do so. An online magazine called Inc is interviewing an entrepreneur per month and asking what each cannot live without. Shane is asking the question: What can't nurses live without? Each nurse answers, taps two more. I'm thinkin this sounds fun.

Nurses aren't 'thing' people. We don't become nurses because we're all about the Stuff. Beth at PixelRN cites good things, that aren't 'things'. I've been reading apgaRN for awhile, and she's not all about Things, either. L&D nurses are all about moms and babies.

I, for one, cannot live without my roadtrips to the desert. See Betelgeuse for latest pictures. But this is not a thing and I do not own it.

And you who read this know me, at least a little. I used to be an entrepreneur. I was literally JustCallMeJo Consulting. (Okay, not literally, substitute JustCallMeJo for my actual name.) I made six figures. I had a $250/hr accountant who finagled my taxes for me. I had stuff. I still have some of that stuff. Now I'm a nurse.

But the question posed is what Stuff I can't live without. Speaking as a person who has downshifted, downscaled and minimized, I can tell you. I'm a stepdown ICU RN. This is what stuff I require:

1. Pilot Precise Black Rollerball Pen
This is not just my favorite pen (I also have red) to use at work for my charting. This is at minimum what I need to tell my stories. I bring out gestures and things I see or feel or think through my oil paintings, and through my quilts, through tiny stitches, and sometimes with my killer watercolor pencils and on occasion through handmade books and often with my good Canon totally NOT automatic camera and sometimes through nitric acid zinc plates and sometimes with watercolors (though everybody tells me my watercolors are heavyhanded). But this is what I need at minimum, have always needed. I am not a writer. Nancy Dancehall is a writer. Writingweb is a writer. Esheep is a poet, (and I'd link you to his blog if he did anything with it.) I know real writers and real poets, and I'm not them. But I need to write, too. I use words. I have to. If I had nothing else...no stacks of cotton fabrics, no linseed oil and turpentine, no pigment...I'd need a pen. Paper would technically be handy, too, but as fine and fancy of a paper snob I can be (artists.), I can use bumwad (newsprint) just fine in a pinch. This post is about what one can't live without right? Need a pen. This is my favorite kind.

2. Body Butter

Technically, I can live without this, but I really would prefer not to. Satsuma is the best kind, though coconut, vanilla spice, and brazil nut are lovely as well. My hands are showing the beginning signs of being not in my 20s anymore (not bad since I'm 35), and it's all the handwashing at work. Satsuma soothes the savage beast and not only do I slather it on my hands and arms at work, I often come home, soak my shift away, slather my whole body with the stuff and sleep blissfully.

3. I'm really sorry about this one.
This is a venti caramel macchiato with soy. I drink one every work day. I switched to soy just in January. Read a book about protein links to cancer, some phD. I'm a lacto-ovo vegetarian and have been for many years, and so now I'm decreasing my milk, though I have no intention of getting rid of it. This is sugary frothy goodness. I require caffeine. After I slam one of those, I drink roughly 20 ounces of plain black coffee through a typical shift. If I ever stopped caffeine, I think I'd have a cardiac arrest or a sudden brain infarct and die instantly. I do require coffee, even on days of no sugary frothy goodness. As I type this, I am drinking a cafe mexicano at my coffeehouse.

4. And last but not least:
Littmann Cardiology III, hunter green, engraved.
I love lung sounds. Still workin on my cardiac sound skills, and it's kind of cool to find a good murmur, of course. But lung sounds? Love em. Not just rales and rhonchi, but give me 'tubular' and post-lobectomies and wheezes and egophony. Love it.

What I Covet:

This is tough. Really tough. Because I am a happy person right now. And what I've got is what I want. I know this is weird. People who want what they've got don't tend to holler that from the rooftops because it's boring and un-American.

I'd like an iPod, but I don't seem to get around to buying one. I'd like a new laptop, as this one's six years old and won't play Civilization anymore. (Best computer game EVER.) I'd like a rosegarden. I have 14 bookshelves full of books and I when I die, NancyPants's husband O can have it all and sell it from his store.

What I do want is a cup of coffee and a window through which I can watch the world. If there's an abscence, it's for lack of a person to sit across the table. I wrote about these things when I started Betelgeuse, and you don't have to follow the link because it's more of my long-windedness. I don't covet someThing. There's a case to be made for the idea of coveting the keeping of what I already have, but. I'm workin on that whole sittin-on-a-zafu and reading Way of the Bodhisattva. No, really.

Now I get to ping two people. Whee! I'm gonna tag Mother Jones, because she's always got good stuff to say. And I'm gonna tag Janet at Chocolate and Raspberries, particularly since she's started to post photos and she's really got a good eye.

Meme fun. Pop over and see what they come up with.

Code White

2007-02-17T10:23:00.000-08:00

If you understand end-stage hepatic failure already, you don't need to look at the prelude post. You know how horrible it is. Otherwise, some of this might make more sense to peruse if you have the time/energy/interest/stomach for it.

A code white is a patient who is bleeding out in my hospital. Though nobody actually called a code white, this is what it was.

This is not the story of Sarah Johnson in room 42. 'Sarah Johnson' is not even close to the woman's real name, and we don't have a room 42. You don't know this patient and you never will. This is the story of what I learned about nursing, what I learned about how nurses learn, as I watched Sarah Johnson's body implode and I watched a team of people Sarah Johnson didn't know keep her alive.

I am bad at fiction, so what I'm telling you is true. Or at least, what I saw. These are the people I work with. It is my hope they don't hate my guts for writing about them. It is my hope, actually, that they never find out. But that's possibly not likely in the long run as I've showed a handful my desert pictures over on Betelgeuse. Dammit. So, in alphabetical order, I give you:

A, the monitor tech/unit secretary
D, travelling ICU RN
M, ICU RN, precepting P
P, ICU RN, orienting
R, SDU (stepdown) RN, who'd been my preceptor

and JustCallMeJo, yours truly, SDU RN

**************

Something big was happening in 42. It didn't take a genius or special spider-sense. I could see men in button down shirts with angry expressions on the phone at the other end of the nursing station. Doctors. Angry. Bad sign. I could see A, whose back was to me, typing furiously with a chart to his side, and the back of his head looked a warmer shade than normal. I could see P, hurrying in and out of 42, brow furrowed. I could hear the phone, and the phone, and the phone. M was calmer, but she was clearly busy...talking to A about paging this person, that person, clarifying with this MD this order, that order. I saw one of the docs I knew, one I'd seen intubate somebody before. She was wearing a scrub hat. Bad sign, meaning intubation was happening again. And I could see R, who was listening to D give him report, but whose eyes kept going up to 42. R is usually in the thick of things of a crisis, and was clearly keeping tabs on what was goin on.

I decided the best thing to do was my job. There was such a clusterfuck of people at 42 that what was needed was not me. Unless shouting and running happened, and then I would run, too. When bumping into P or M in the medroom, I told them, "If you need anything, let me know, my patients are fine and I can help." They said thank you, they're okay. M said this kindly, P said this with dubious belief. Or maybe that was just her stress level. Neither M or P knew me at all.

I noticed that R got his admit across the station from me, and B, the resource nurse was helping him and apparently nobody else. This is a bad sign because it meant that neither P, M, or D was available to lend a hand. Everybody is around to lend a hand when an admit comes. So I poked my head in, though by the time I got there, R had his patient settled.

I tried to stay out of the way of 42. Traffic slows because of rubberneckers. And I don't know enough to be useful. But as the evening progressed, one by one, MDs began to leave and the tension level decreased a little. I listened. I hovered, and I gathered that Johnson was bleeding, had been bleeding. P and M were back and forth, in and out of the room. P: "Where the hell are my platelets?!" M: "A, would you page respiratory for me please?"

(Rehab just called me. Can I come to work there tonight?...Er...sorry, been up all day. Besides, got a hot date with my best friend and her children today.)

D and R were doing their own thing. R busy, D mostly goofing off. I saw R hopping on the phone to page people for M and P. Getting stuff, helping. D hovered and told me that the patient was "bleeding so much that she had a yankauer up her ass". This is horrifying until you see how eminently practical and oddly humane it is. Would you rather have the patient bleeding out of her ass and lying in it because she's so heavy to move, have her family see her in that state...or would you rather find a way to keep her cleaner, even if it's a little, um, unorthodox? It sounds so horrible. It is horrible. So is the alternative.

P came out of the room at one point and I was the only one sitting there. Her expression said that I was clearly not her first choice. "JustCallMeJo, do you know where the blood bank is?" Yup, sure do. "Would you take these units down for me please because I'm only supposed to give them if her crit is x and we may not need them until midnight." Sure, I can do that. So I did, came back, loitered more. Maybe I could do something else. Learn something.

I caught little things. A needed to eat, and with his face that color, clearly needed to step away from the desk. There I was. "Will you watch monitor so I can get some food?" Sure. So I watch monitor, notice nothing more than occasional PVCs on two of R's patients, and take a huge number of calls for P/M. "M, Dr. Somebody is on the phone for you about Johnson." She nods, "Thanks. Johnson is P's patient, and I'll let her know." It was a gentle correction.

And I thought about that gentle correction. Here's a woman who can clearly handle this patient. She'd need help, of course, because no patient this complex gets better because of any one person, including and especially not because of any MD. Don't make me laugh. And what is this nurse doing? Holding up another nurse, supporting another nurse, one with less experience. And she did it....gracefully. I admire that. A good mentor is rare.

P needed more from the blood bank, and I was there again. "I need 2 units of FFP now, and see if they'll give you those two units." "Right. Two of FFP, two units if they'll give them." I returned with my hands full of stuff, which allowed me my first real look into the room.

love of god.

Bright lights, beeping, whirring. The patient was intubated. There was blood, yes, and oozing fluids. She was covered by a gown but she had what looked less like vaginal bleeding as what had been vaginal gushing. She was yellow. She was huge. She was massive, actually. X's marked the place on her feet where pulses would be if you could feel them. And there was a bank of IV pumps no less than five feet wide. Think about how wide five feet is. She had no less than seven lines infusing into her just from the IV pumps. And there were five lines hanging from the ceiling that were run-as-fast-as-you-cans, platelets mostly. Blood products and blood products. On the other side of the bed, there was a small fridge-sized portable dialysis running. (I didn't know this was a dialysis machine, I had to ask.) The patient had a tube down her throat, a ...let's see octo? lumen? subclavian in her right side...what do you call a subclavian with two or three "chicken feet", foley of course, the suction, and a vascath in her femoral, filtering blood, and oh, I think another miscellaneous IV bank in her left arm, too.

She was yellow and unconscious.

And seeping. Fluid seeping from her skin.

It appeared that either the bleeding was under control or the suction was taking it away and dumping it into tanks under the bed.

P and M were deep in conversation about some charting thing when I timidly walked in and handed them the blood stuff. "Thanks," they said, and then I kinda just didn't go away. I put my hands behind my back to not touch anything and I looked at the IV banks. Vasopressors, insulin, a few meds I didn't even know. "Is it, um, okay, if I look?" M nods, smiles. P shrugs, sure. P is focused on learning and stressed because well, this is her patient. She's digging this patient out of a deep fucking hole. I get that. I respect that.

So I try and stay out of the way, and listen. A GI doc is coming and gonna scope her and see if he can stop the bleed. I had to refresh my memory of hepatic failure later, but even as I heard that news, my eyes went huge because I was thinking: esophageal varices. I mean, the GI tract is really really fragile right now, right? This is risky, right? So my eyes popped and I shut up. Probably I just don't know what I'm talking about. I shut up, I listen. This is my job today.

P hung one of the platelet bags, and in a voice I hoped sounded unobtrusive, I asked, "So...P...you can just slam those in? You don't need to do a specific rate...?" She looks at me as if just noticing me for the first time. "Yeah, you can just run it with a bulb like this." "Because we at the opposite of caring about CHF type stuff, right?" "Yeah, her fluid volume is so low right now, it's hard to get a pressure."

And after that, P looked at me with less dubiousness. Maybe it occurred to her I wasn't a toad, nor was I a fluffy bimbo, and she had stuff she could teach me and I was more than willing to learn from her. At least, I hope that was it.

I tried to not get in the way, but I felt like I could watch. D hovered as the GI doc came in. D was having a ball. D was like this imp, buzzing in my ear. "I love this stuff....I love it when I'm so busy I can't even leave the room to take a piss....this is a great learning experience for P."

It wasn't just D that offered to teach me things, either. M said at one point, "You know, JustCallMeJo, she's got a really good example of scleral edema." P nodded, "Yeah, JustCallMeJo, come here and see this." I stood behind her, gloving up. P gently opened the patient's eyelid to show me, and then stepped back to allow me to do the same. My god. Her EYEBALL was swollen with pocketed fluid. There was something comforting to me about just gently touching this woman's forehead. I was careful. Her goddamn eyeball was swollen with fluid. I don't know what it is about things wrong with eyeballs that is just so fucking wrong.

But no time to think on this. We had things to do. Or rather, M and P had a lot to do, and I had getting out of the way to do. The GI doc arrived. Gowned up, machines brought in, things to move out of the way, more blood to get...

It was D who looked out for me. No special reason why that should be unusual, but R'd been my preceptor, and it seemed strange without him. Especially when What's Happening was in room 42, and in my limited time I've been on SDU...R thrives in a crisis. No time to think about it, though. D called me to come stand in a good spot and buzzed in my ear. When the doc would ask for something, D would hop up and get it. M and P were too busy. Handy, as I realized I still don't know my unit so well as to know where to find say, a tongue depressor. Who uses a fucking tongue depressor in ICU? Somebody who needs to open an unconscious patient's mouth, that's who. M and P were so slammed busy with the five foot wide banks of IVs and getting blood, slamming it in, trying to keep a blood pressure...I'm not sure that either of them got to actually see what was happening with the scope itself. P got to look up once. I'm not sure M saw it at all.

D was my running commentary. My eyes were riveted on the theatre happening in front of me, but I was listening. Once in a while, I'd fetch something. I would go eyeball my patients here and there, make sure they were breathing and doing fine. It helped a lot to know that A was at the tele desk. But I tried to be present as much as I could for the scope. (This scope = laproscopic exam from esophagus through duodenum) Some things D said I knew, some things I did not. "They're probably in the pyloric now...I've seen people come back with this and be completely fine after a transplant..." At one point, I think he was watching me and not the scope, and he said, "Welcome to ICU." I acknowledged I'd heard, but I was still looking.

Art school. You learn to look well. You learn to memorize gestures and colors.

I kept wondering to myself why R didn't hang and watch, too. Like I said, R's usually in the thick of things, and I was puzzled but I let it go. I tried to nudge him a little once or twice, but the effort fell flat. Possibly his new guy was a handful and he had a brief moment of respite, or there were already enough cooks in 42. After he'd lended a hand early on, he stayed out of the fray...fray-adjacent. I may be misreading, but there might have been brooding involved, brooding of unknown origin and no doubt not my business. I like R, he's a good guy and a good nurse, far better than me. He's certainly been patient with me. He belongs in ICU and due to life factors, he's not there at the moment. I let the invitation to come see the scope sit there, and then well...back into the fray.

The GI doc closed a bleed and he and his RN left. The scope showed a clot as huge as my hand in her stomach. It had been a helluva bleed. I'm not sure if he got IT, but he got one.

Cleanup time. This was something I felt like I could do, I know how to help, so I did. It took six of us to change the patient's linen, full of blood. And the second we got new sheets under her, the new ones began to darken with more blood. I could also take out the biohazard, I knew where that went. I can take out the trash, too, I know where that goes. More blood tubing? I can bring two types of blood tubing. So now I have learned which blood tubing is needed.

We were beginning to unwind. Sarah Johnson was gonna stop bleeding. Or at least slow the bleeding. This was what was unwinding. We saw the clamp. We got blood slammin in, and plates and expanders, and milk of amnesia so she never knows. Dialysis pumping it out and 14 or 15 lines pumping it in. Sarah Johnson is gonna make it through the night and today was definitely P's day.

Nobody knows that it's P's day but those of us who were there. She nailed it. She really did. I overheard her and M debriefing much later in the night, a really important thing to do after all that. "What would I have done if I had to do that by myself?" And you know what M said? "You would have had JustCallMeJo and R and D to back you up." She's right, and I think that's the best part of everything I learned that day. Had she been alone, I would have backed P up as best I could.

P was bulletproof at the bedside. Yeah, she was stressed, yeah she asked M stuff, her nerves were jangled, and M and D were rolling much better with the situation. But she got the job done, and that is *all* that matters to Sarah Johnson's family.

M was bulletproof because she didn't step in and do FOR P, she did better. She stepped aside and let the RN who will become another awesome person taking care of patients of this complexity do the job. This is not stuff you can learn from a textbook. This is stuff you can only learn by being there, and doing it. Somebody's very mortal coil is depending on you and the team of people you're with, and so this isn't something you can really practice. You do.

Think it's the doctors who "save lives"? Yeah whatever. They play their part, they go home.

Besides, I prefer the term "stopping someone from dying." Life saving is for pastoral types.

I fetched stuff. I took out the biohazard, I watched. I helped turn and asked questions. And what was cool is that D was there to buzz explanations to the least person in the whole group, i.e. me, the chick who took out the trash. And that chick was grateful to take out the trash, ...just to be there.

And A? A kept the chaos at bay. The static and noise of phone communication and flying orders and nonsense of delayed blood product and get me a respiratory therapist and no time to delay because this woman is bleeding to death. A rolled with that and also, by the way, watched the heart rhythms of 12 other patients.

R joined us as the cleanup happened. It's possible that he was having a completely different patient crisis, of which I wasn't even aware.

Sarah Johnson's alive (or was when we left), survived the night and neither she nor her family will know what was involved to make that so.

You have no idea how proud I am to be the person who fetched the extra blood tubing.

During cleanup, D went back to his goofing-off self, munching out of a bag of popcorn. ("I'm really hungry. Is that weird to be hungry after I just watched a GI scope?" "I think it's healthy.") He asked me, "So is this better than rehab?" Rather than answer, I grinned back. A grin that wasn't just 'yes' it was 'hell fucking yes'. It was a dirty grin, an evil grin and I didn't actually intend to flash it at him. So I turned back to fiddle with the biohazard bag, but not before the point was made.

And I didn't sleep. I was awake 23h. And this post is a poor reflection of what happened. I don't think I really caught it all. It's an echo of an echo two days later.

I don't know if Sarah Johnson is alive today. When I told Katie the cliffnotes version of this story, she said, "Well, you can't....maintain that kind of thing, can you...? Putting all that blood in nonstop? I mean, what's gonna happen?"

I don't know. I really don't know.

I know it'll happen again sometime. Liver failure does. And I'll know which blood tubing is the right one, and where to find sharps containers.

That's worth something to somebody, isn't it?

Liver failure: prelude to 'Code White'

2007-02-17T08:50:00.000-08:00

You need to read this post to understand the one I'll be writing down next. Because, now that I'm pulling my thoughts together, there are two big things I learned about as a nurse this week. One is a few things about clinical pathophys and presentation of liver failure. The other is a few things about how nurses treat and respond to the crisis of liver failure, and in this case fulminant liver failure.

Liver failure is a bad way to go. Most nurses can tell you there are better ways to go than others, and liver failure is not a good one. If you're considering alcoholism as a life choice, please reconsider. Massive MI is a better way to go, but the problem with that one is that in lathering up those arteries, you might just end up with the long suffering of CHF instead. Also, do NOT overdose on tylenol, as this leads to liver failure as well. Use condoms, as you do not want Hep B or Hep C. Wash your hands, as you do not want Hep A. If you use IV street drugs, (not a big recommendation for a host of other reasons), for god's sake, autoclave.

Kim from Emergiblog is an ED RN, and she rocks, as does her blog. Months ago, she did a gutwrenching post, and it's beautiful and has stuck with me since. Here it is.

Some patients seem to hit you on an emotional level, as Kim's did. Some patients interest you clinically, as this one did. Nurses do not tend to be the people in your health care world who forget ever that you're a person. I touched this woman's forehead to see her eyes, and I did so gently because this woman happened to be somebody's Mom, somebody's wife. But as a clinician, I was interested in the machine of human beings working their asses off to save her life. I was interested in what was going on with her body. I was interested in who did what, what roles functioned to do this thing to keep her alive.

This is why this is the first post I'm gonna label "learning ICU." Not because I haven't been for the past 6 weeks, but this is the first time I might have learned some vocabulary words to tell you about critical care nursing.

For non-clinical people:
You know that alcohol abuse and viral hepatitus can crash your liver. You might not know what your liver actually does for you. I mean to say that you know these things are bad, but you don't have a specific picture of why, exactly. Something to do with being yellow, probably.

* Your liver filters broken blood cells, bacteria and nitrogen out of your blood. Let us consider the example of "laughing gas", which is nitrous oxide. What happens when there's too much nitrogen (which is actually in the form of ammonia) in your blood? In small doses, you may feel silly. In toxic amounts, you're beyond crazy and you're in a coma.

* Your liver gets rid of this gunk called bilirubin out of your body. Bilirubin is what makes the skin yellow in people with hepatitis and newborn babies, whose livers learn after they're born to break down the bilirubin. Most babies are born a little jaundiced and it clears in a matter of 2 days. I had hepatitis in 1990, because the mono...a virus called Epstein-Barr, overloaded my liver. I was yellow and felt like hell for 6 months.

* Your liver metabolizes drugs, vitamins and hormones...meaning it breaks them into substances your body can use. Without that ability, your cells aren't getting fed nutrition, and drugs that your nurse gives you to do important things like regulate your blood pressure or heart rate or whatever, are not as effective.

* Your liver helps regulate blood glucose via glycogen stores...glucose = "cell food". It also metabolizes fats. A double-whammy of nutritional deficiency.

* Your liver makes certain proteins, one of which is called albumin, others relate to blood clotting called fibrinogen and prothrombin. Let's start with clotting factors...that's easy. If your plasma, the goo your red blood cells float in, does not have clotting factors, you don't clot. Ergo, you bleed. The less factor and fibrinogen in the blood, the more bleeding. You can see where this is going.

* Albumin is a happy little molecule that transports hormones around your body. It's bigger function, however, comes from the fact that it's big. I want you to go for a moment back to high school biology and chemistry and we're gonna talk about osmosis. Big molecules act like sponges and draw water to them. Wikipedia has a wonderfully egghead explanation. But what I need you to know is that big molecules suck water closer until there's stability between say, what's inside your veins and what's across the membrane of the vessel wall.

Again, with the what does this mean thing? If you don't have albumin, you leak. You leak abundantly. Your blood vessels shrivel up from losing blood volume and you lose blood pressure itself and your body swells up with fluid because all the water IN your body isn't usable to you. You swell with so many pounds of useless fluid that I can make a thumbprint an inch fucking deep into your foot. Your skin leaks clearish-yellowy fluid from any cracks of incisions made, such as IV sites, or anywhere your skin may have been broken.

You are a giGANTic sack of fluid-filled skin oozing your yellow self everywhere, beyond cognizance because of the nitrogen or ability to breathe on your own because of the metabolic acidosis. Your kidneys are dead because your kidneys require blood pressure. Then there's that other small detail of not having any blood pressure, so your heart is gasping for something to do in the time it has before your blood pH and the lack of usable potassium stops it dead. You're probably getting IV lactulose, which is a medication designed to give you constant bowel movements because that gets rid of some of the nitrogen. Oh, and there's the bleeding in addition to the oozing and the shitting. And the most likely place you'lll bleed? Your GI tract. What blood you have, since it can't go through the liver anymore, rerouts often through the veins in the bottom part of your esophagus. These are called esophageal varices. Your GI tract? Big long tube from your mouth to your ass and so you're shitting copiously, and now you're bleeding copiously out of your ass, too.

Fortunately, at this point, you are probably beyond awareness of any of this.

The unfortunate part is that your family members who love you might be watching.

love
of
god

This is a PERSON I'm talking about.

This is a PERSON.

christ.

geezusfuckingchrist

I know you're not wondering now why I had to write this to get it out.

I'm so glad I lost the belief that god/dess/GiantTurtle is responsible for anything that happens anymore. Because I'd be mad if I did.

Instead, I am staring at a gaping hole of entropic causality. I don't feel better about it than you do, probably, but I am not angry. I believe 'existential horror' covers it. There can only be two outcomes of existential horror. Sartre found it in a bullet. I think the only way out is compassion. I'm certainly not the first to draw that conclusion. Taking that complete rainbow in the mist and giving it away as fast and fully and completely as you are humanly able. And that's why there's a part two to this story.

Something I want you to know, too. Lest you are one of those assholes who think that alcoholics deserve this fate, I will tell you that this patient was not in hepatic failure because of alcohol. Nor was it viral. There was not a single lifestyle predisposing factor that caused her liver to die.

Nobody deserves what that woman got.

Pretend to care.

2007-02-15T07:20:00.000-08:00

Once upon a time, there was a Dilbert computer game and the evil boss people would constantly chide you: "Pretend to care, PRETEND TO CARE."

Dilbert was funny until you lived it, and then it was humorous pain. Millions of people understand this same existential state. Sartre for Dummies. Doesn't matter what country you live in or language you speak. Absurdity is real and indomitable.

So PRETENDTOCARE was running through my head after a talk this morning with J, another NOC stepdown person. He was The New Guy until I arrived. For advanced practice school, they're having him attend Meetings. It's cruel of them, really. So he's going to QI meetings...QI means Quality I...Insects? I...I...nouns that begin with I.

(What does it mean if 'imbecile' and 'idiot' come to mind and oh, NOTHING ELSE?)

These QI people, however, are quite smart, regardless of what the ignominious (see? I can come up with adjectives with I) I nouns in their title. I faintly know two of them, and at least, they are smart. I'm gonna go with my gut and say other smart people are there, too. (My gut also tells me that at least one person at the table is somebody the rest of the people at the table want to throttle. It's a universal truth. You cannot come to a meeting without at least one village idiot.)

Improvement. I betcha it's 'improvement'. That took wayyyy too long. Sorry.

What's happening is that J is getting ensnared the way I feel like I am, too. Like a fly who touched a strand, and then another and another until I am a dry, hollow husk dangling in the breeze, discarded in a greyed and moldy cobweb.

Yeah, that really is preCISEly the image I'm living. It's corporate purgatory I fear.

J has the same problem as me. He cares. He, like me, may hate caring, but he cares. I do like going to work to do my job, leaving it there and coming home. This doesn't always happen. For anybody. But when I see something stupid, I kinda wanna fix it. MyHospital does some stupid things. And they're big stupid. It's not about my unit at all. When I hear things about how the big Meditech Rollout is er, NOT going, it irks me because it's gonna disrupt my ability to do things for my patients. When I know how rehab is kept attached to MyHospital like a gangrenous limb that nobody talks about, I kinda wanna say, "You wanna be a Magnet hospital with THAT putrefying thing dangling off 4east?" I go to these Town Hall Meetings with all the mucketymucks and they'll have FIVE new initiatives and directions for Porter. Who ARE you people?

They are MBAs.

And this is what they do.

Many wonder why they're ineffectual and the status quo is continually reconfirmed. They really do. Ask one, and many will have their insides chewed out of them wondering why their Visions don't get implemented. Many are genuinely baffled at why their efforts to improve x or y don't happen.

This is why I was a consultant. I really did read _Spiral Dynamics_. Cover to cover. (It's a sickness.)

And you know what? I just wanna be a nurse. I really love taking care of my people. I have a huge amount to learn still and I'm all elbows and scabbed kneecaps. I feel like a burden because I'm such a freshman in my new home. I'm really workin on it. I flub, and fatfinger, and I wish I were bulletproof.

And yet, some people want me to come to meetings. Somebody told J, "JustCallMeJo is just what we need at nurse practice council." For real. He told me that. He had Dead Serious Face. I was mortified. If that were true, we're doomed. Doooooooooooooom.

J's next. He is. They got him, too. He's gonna start coming to NPC, too. At least we can commiserate. Pretend to care PRETENDTOCARE.

Change of Shift is up!

2007-02-09T07:45:00.000-08:00

...with loooooove in the air. Put on some Barry White and check out the fun at Nurse Ratched's Pad.

Thanks for including me, MJ!
/jo

p.s. Oh, and Kim @ Emergiblog does commode poetry. BWAHAHAHAHAHAHAHAHA! I'm a nurse, and therefore it's okay to laugh at potty jokes. I'm a professional.

Colorado SB10

2007-02-05T18:08:00.000-08:00

The Colorado Senate Health committee heard opinions and discussion on this bill on 2/1. The bill is found here in entirety if you click on Senate Bills.

I'm feelin funny here.

I went to Nurse Practice Council last month, and my hospital is working on its Magnet stuff. Our CNO brought the bill up at the meeting and said that she intended to testify in opposition to the bill, but she wanted to hear what MyHospital NPC had to say on it. Was she speaking for us? She wanted to know.

So I stuck my hand up.

(Me and that sticking my hand up thing.)

I wanted to know why she thought it was a bad bill. Her rationale was brief because we were short on time, unfortunately. Her main point was that staffing metrics is not the best measure of good patient care, and that to mandate that we hire someone to do staffing ratio reporting was not in nursing's best interest. Any patient that wants to know staffing ratio can call and she is happy to tell them, she says.

Okay.

I listen. Unfortunately, I had not read the bill before this discussion, knew nothing about it. So when asked if I'm on board with MyHospital Nurse Practice, I kinda had to sit back and ....say I didn't know. I hadn't read the bill. I had questions. How did it work in California, and according to whom? Is the bill truly a slippery slope to mandating staff ratios, which I do think is a bad idea for some governmental body to be deciding how many patients a nurse can take. What does the government know about health care? About my patient? No, that's a bad idea. But do we throw out a good bill because there might be another proposed bill to follow? That doesn't make sense either.

Colorado Nurses Assn supports the bill. I'm a member of CNA/ANA, too.

I don't like kneejerk reactions to something important. I don't make quick decisions when it counts. I wished I'd had more time to sit and stew on this before being asked if I was on board.

The good news is that there's a staff RN from my NPC who's gone to the senate meetings, and he's telling us what's up. No votes were taken on it yet. I think the testimonials went so long they decided to re-address another day. Most of the testimonials are coming from administrators of CO hospitals. As these are people who will have to cut the checks for the fines, I'm not sure that they should be the only people to stand up and have something to say. By all means, participate in the discussion. I'm not a fan of fining hospitals either, as that helps neither the patient nor the nurse.

But.

There are some really good ideas in that bill. Ideas that can help patients. Ideas that can help nurses. Important implications for models of care.

I've heard, through my CNO, that "it didn't work in California when they tried it...they're not happier there." Okay. Except. I had a breakfast long island iced tea on Sunday with L. And I know L. I worked nights with L for a year, and I trust her and her thoughts on things. L was, incidentally, an administrator at a California hospital before she chucked that and came back to bedside nursing here in Colorado. I trust her. And the story she told me about how that staffing ratio reporting thing worked in California was different. Yup, hospitals got fined, but the nurses were happier with the care they were able to provide.

So I don't know.

Part of me really kinda wishes I worked some days and could go sit in on these meetings; I'm sure they're open to the public. I guess I'm not just "public" either...I'm an RN, BSN, member of CNA/ANA as well as my hospital's NPC ...but I think my primary distinction is that I'm simply Not A Schmuck and I know a thing or two about what I want and need to take care of my patients.

You know, I read Suzanne Gordon. I think every nurse ought to.

I'm thinkin this is where the rubber meets the road.

I wish my way here were clearer, though. If it's a good bill, heck yeah, I'll go write my letters to congress (and have written, incidentally, within the last three months). But good/bad isn't so straightforward here. I'll go stand up for the right thing. I'd even go stand up regardless of whether or not my CNO shares my opinion. She's a smart woman. I respect her. I respect that she'll go stand up because she thinks this is a bad bill.

I haven't decided if this is the right thing or not.

Is it really eat the young?

2007-02-02T23:21:00.000-08:00

Nurses talk to each other about how we eat our young and how that's shameful.

True. Reasonable.

But then, maybe it's not about age. It's about gender, perhaps, and about complex social issues of female-dominated workplaces and Empowerment and how we socialize each other to not have power and Womyn With A Y and menarche/menopause and other gagworthy propoganda. Maybe that's not fair to dismiss the latter idea with sarcasm, because I do regard it as chick schtick. The point is taken by Suzanne Gordon, and the case is reasonably made. I just don't agree.

Ninety percent of my new colleagues in ICU have been on a sliding scale from wonderful, professional, welcoming and enthusiastic at one end to indifferent, reasonably polite and reasonably professional at the other end. Who could ask for better? Nobody. (Not anybody realistic, that is.)

There's always at least one. It's a workplace, and no matter who you are, what field you're in or anything, there is always at least one. It is to my utter bliss that so far, there only has BEEN one. This one happens to be younger than me.

But now that I'm thinkin of it, this unpleasant hazing was done to me in the IT field as well. There's always a small handful in every office and on every contract. The geeks who don't help. Geeks who purposefully obfuscate. When you're a geek, it's laughably easy to blind your (non-geek, if you have them) friends and family with science. You get awe in return if you're speaking to someone who's impressed by that kind of thing.

But I've been hazed with the Blinded By Science bit; I've been hazed by the weirdly passive aggressive I'm Going to Fill Up Your Whiteboard With My Formulas And Don't You Dare Erase Them; I've been hazed by the room full of 15 men talking about the Tijuana stripclub the night before (and I'm the only woman there, and by the way, nobody invited me, which was the aspect of it that annoyed me more). This chick can code circles around me, maybe she'll take my office and the esteem and awe that every other Poindexter here has for me. Of the handful of geeks who've done that to me (and to all newcomers), the vast majority of them get over it. The ones who don't are the same ones who didn't get over it with the guy/chick hired 7 months before I was, anyway, so everybody knows That Guy's Just A Prick.

So I'm getting hazed again.

It's boring.

I mean, really. I'm not offended. It doesn't hurt my feelings. Nor am I...I dunno....what does one typically feel when one is on the ass-end of that whole Eating The Young (irrespective of age issue)/Hazing The New Girl Thing? When it happened in nursing school, which is where you see it a lot....Are you threatened? No. One doesn't feel threatened when someone else is acting as if you're a threat.

In my case at the moment, I don't know that 'threat' has anything to do with it. I don't know what the source of the malfunction is, actually. But ...I have to tell you it's weirdly liberating to not ...care.

And it's really that more than anything that has me thinking. It's about this parking my butt on a zafu to meditate business, at the root. So in circling how to write that over on Betelgeuse, I'm writing how it's affecting work here. This is my life in nursing, and to have a life in nursing, you will hit the adage, Nurses Eat Their Young, pretty much immediately. I guess....I'm not feelin readily digestible. That's not an analogy I'm willing to take further, mind you. But it's got nothing to do with age. Or gender. Maybe it's just people. And maybe you can ...step outside of that stupid little dance altogether.
/jo

Love of god, eat some vegetables

2007-02-01T07:28:00.000-08:00

You ever have one of those patients who come in, and you read their history and physical and you think: LOVE OF GOD, MAN/WOMAN! DID YOU EVER IN YOUR LIFE EVER EAT A VEGETABLE?!

Maybe that's just me.

When at least three coronary arteries are over 70% stenosed, and your ejection fraction is in the toilet and you're having syncopal episodes cos, GOLLY, no blood gets to your head when you stand up....

(Translation for the non-medical person: your heart sucks)

I mean, I'm seeing these postop hearts night after night and what keeps boggling me is how proFOUNDly preventable all this sturm and drang is. All the pain. All the...did they mention the bit where they saw into your sternum? That leg that has blood running down it all the time cos I can't change the dressing fast enough and you're too set in your ways to elevate your legs in bed cos you've got 2+ edema and you've been sleeping in your recliner for the past 15 years of your life and want to do it here...?

This is why millions of Americans can't afford insurance.

Because people with insurance don't eat their gd vegetables, they get sternum-cracking-open sick, and it costs tens of thousands of dollars to slap veins onto where arteries are and/or put pig valves in where your old valves have worn out and/or just roto-rooter your carotids ....

And are we teaching these people in the hospital how vital it is to stop eating eggs and sausage for breakfast every morning?

No. We are not.

We see them a year later for pulmonary edema or kidney failure.

NOCs: the Art and Culture of Not Calling Your MD at 0230

2007-01-22T12:20:00.000-08:00

I am a nightshifter by nature. I don't enjoy chaos and I like to work autonomously. Nightshift tends to be less chaotic just by virtue of less cooks in the kitchen, and all family members are verboten from our unit after a reasonable hour. Less hysteria that way, for good or ill that policy is to the family.

I finished my first night shift last night, still orienting. And invariably, much of it was about When Not To Call the Doc. I think there are hospitals out there where nurses will call whenever an issue arises. I'm not talking about the "I'm dumb, can this patient have some tylenol at 0300?" Nor am I talking about that ever-professional "That resident was rude and arrogant and I'm going to call and ask if I can give the patient a suppository at 0300."

I'm talking elderly patient whose Afib goes uncontrolled...from heart rate of 90s to high of 138, O2 needs increase from 10 litres to 16 via mask/NC. I'm orienting with R, who's been in stepdown for 16 months, mostway through NP school, and his executive decision was Do Not Call. Rationale was: give the Lasix 3 hours early and watch. Which, okay, reasonable plan because everything pointed to Fluid Overload is the problem.

It was a plan I went along with. Remember, still orienting to unit until end of the week.

But not a plan that doesn't make me feel a little funny. Because uncontrolled Afib isn't a stupid reason to call. And the patient's primary care MD called us at 2200 to check on the patient. This is a PCP who cares about this person. And you know what? Gradually spiralling out of control atrial fib is a good reason to call even when the MD doesn't give a damn.

I don't think I like a culture of Let The On-Call MD Sleep At All Costs. (Not to suggest we were doing that in this instance...there is an element of that on my unit at large, however.) Because the MD is getting paid to be on call, and I never call for stupid stuff, nor am I unprofessional with pages. On my old unit, I was not once wrong to have called and said, "Here are the symptoms; here are the vitals; here are the labs; this doesn't feel right to me at all." Never once had it been for a reason that either sent a patient to the ICU before the crash happened, or was some other disaster averted so the patient was either kept out of ICU or restraints or pain. When I know I might want a stinkin sleeper, I call before 8p.m. When the patient's had a procedure I know will hurt and the inexperienced PA doesn't, I ask before the PA heads home for the day.

My hospital has this culture of Not Disturbing the MDs. A 15-year veteran ICU nurse stood on a box and railed about this to me last night. I don't know if she's right or not. Under his breath, R muttered to me later, "She's a little negative."

I'm still in observation mode right now. I can tell because when I give report in the morning, I'm not as on the money with the extensive health history I should know. I know about last night, but not about last year, and when it's MY patient, I make it a point to know everything about them. I don't feel ownership yet.

When it's MY patient?

I'm gonna call. I practice nursing, not "medicine" (as if nursing is somehow dichotomous from "medicine"). The two work together. And when I don't call, I am practicing medicine on a critical symptom I decide the MD/PA can wait on knowing about. I know what my scope is. I know what the problem is, can understand the most likely patho, can take the reasonable steps to control the problem, and I can tell you what the likely drug or fluid and dose s/he'll order and for when, and what followup labs or tests.

So what do I need the MD for? Nursing has a crisis in part because if all the above is true (and it is), why are we paging the MDs?

Thing is, when I go home, the patient is no longer mine. I see it all the time when there are too many MDs, cooks in the kitchen, driving the plan for the patient. But for every MD that works with that patient, there's at least four nurses. Most patients in ICU/Stepdown have a CV surgeon, cardiologist, pulmonologist, primary care physician and many have an infectious disease doc.

Ideally, every nurse that works with the patient knows that say, the patient is just shy of throwing her kidneys to hell and wouldn't order an emergent chest Xray with contrast and by doing so, make the final nudge into renal failure. Ideally all of them know that the patient was in and out of Afib on Tuesday, too, and now it's Sunday and it's happening again. But the reality of the hospital isn't ideal. Maybe the 80mg Lasix IVP does exactly squat for the patient, that isn't the patient's issue at all, her neutrophils show a staggering 98% of her wbcs and we anticipate pneumonia and we should be preparing to intubate.

The MD is supposed to know the patient. They take care of a lot of patients. But in no month or year do they take care of as many patients as I do. So I guess I'm sayin I'm quite comfortable knowing Typical Interventions because in the majority of Situation X, Intervention Y is gonna be dead-on and I'll be doing the right thing by exercising judgement to go forward with it.

I want to be smart at this new job, you know. I want be able to manage a patient's crisis by myself as much as possible...that is one very good reason I work nights. But I think maybe being smart is knowing also where you stop and someone else comes in. And since I'm new to ICU, I think that point-of-where-someone-else-comes-in is a lot earlier than a heart rate of 138 and oxygen needs increased by 75%.

I'm not saying that what we did was wrong. I do think R's right, it was fluid overload, Lasix'll pull it off. I'm sayin that point of where-someone-else-comes-in is a lot later for R than it is me. He's been at this longer.

For good or ill to the physician's altered sleep pattern, they'll probably hear from me more for a while. It's not my favorite plan, either. Nursing doesn't have formal residency and because of that you have these awkward dilemmas. You want an expert nurse for every patient in every situation.

But you gotta grow em.

Tikosyn

2007-01-17T19:26:00.000-08:00

I haven't been writing much about stepdown because I don't think I've chewed on it enough. It continues to go good. I'm up to 2.5 patients today (meaning 2 and an afternoon admit), so I'm right where I should be. I gave Tikosyn today, learning how to calculate a QTc value.

My folks are very supportive of the new gig, and Mom often says, "I want you to build your skills, get really good at putting in IVs and stuff." It's great to have their support. Setting an IV is the lincoln logs of what I'm doing in stepdown, though. (Incidentally, I did start one today and nailed it, yay me.) (On a dehydrated 78 year old.)

I'm not sure that I can put together yet how bigger a deal it is to give Tikosyn and deal on my low 40s sinus brady post-ablation patient than it is to set an IV. To the general Joe Anybody, drugs are something that you go home with after you see the doctor/PA/NP and you generally take them as the doc/PA/NP prescribes. But so many drugs in ICU can kill you so quickly and so easily if you don't watch specific stuff that there's a whole world of pharmacy out there of Crap That Can Kill You, Unless You Do These Exact Things In Which Case It Will Keep You Alive.

Tikosyn is given to prevent or keep a person out of atrial fibrillation. Atrial fib is when the top portion of your heart beats at 250 to 400 beats per minute, and the rest of your heart does not. The heart is your pump, and when the top half and the bottom half aren't doing the same stuff, it means your pump is ineffective to say the least.

Every drug lists adverse effects, which are side effects that a percentage of those tested will have. At the dosage my patient was on today? The most common side effects are ventricular tachycardia or torsades des pointes. By a QUARTER OF PATIENTS in one study. What is ventricular tach and torsades? Heart rhythms. The worst ones. (Other than the flatline you see on tv. Which, yes, technically IS the worst.) Means you're getting CPR and being shocked back to life if you're lucky. And if you are not lucky, you are dead. People that die "from a heart attack" die from one of those rhythms.

And it's a pill. Tikosyn. Lemme tellya how weird it is to hand that pill over into a little med cup. And my patient is a sweet woman, who is cheerful and cheerfuly trusts her little blonde nurse. S said it the other day when she said that in her 25 years of nursing experience, only one person has ever asked to see her license. She introduces herself as a nurse and patients trust her. S, being an NP, has prescriptive privileges, too. She is extremely thorough when she writes scrips. People trust her more than they do MDs. They often trust me more than they do MDs.

You say you're a doctor and the world thinks that implies something. Some list of things, maybe. Sometimes they're true, I suppose. You say you're a nurse, and that implies a whole set of other things....that you're automatically a good person, an honest person, a caring person, and the most nauseating: "an angel" (Pardon me while I hurl.)

I think most of us are good people, honest and caring people. Some of us do our jobs okay and get that secondary benefit of being seen in that light. Because we're often not honest or good to each other. I knew a nurse that stole drugs. She's not a nurse anymore. Probably, fewer nurses cheat on our taxes or steal cars or whatever than the general population. Probably not a lot of nurse serial killers, silly fiction notwithstanding.

And my patient smiled at me as I gave her the little green and brown capsule. "Thank you." She said she could read everything on my face, my patient did today. I had pensive face and I knew it: "Now I want you to tell me the second you feel anything weird: heart racing, dizziness, lightheaded, anything, okay?" She continues to smile, "Sure thing, honey." She has unconcerned face. Maybe because she sees my pensive face and has this amazing trust that Pensive Face is going to ward off any problems. She has no idea how much I hovered around her tele rhythm all day long. I know Tikosyn is a good take-home drug for many people. They don't know that pharmacies have a specific extra protocol for the drug, or realize that the drug's first five doses are always given in a telemetry hospital bed by some law or official guideline (and pharmaceutical companies don't strike me as the kind of people who'd make inconvenient rules on their own drugs unless they had or were anticipating $$ lawsuits).

She just popped it in her mouth and washed it down with fresh ice water.

Smile.

My mom'll be proud of me today that I set an IV.

ICU Stepdown is just. Even I as a nurse didn't know all there was out there.

Little green and brown capsules. Just a pill like I'm givin baby aspirin or somethin.

*****

I visited my old unit after Nurse Practice Council Monday. I discovered that the elderly nurse I'd worked with most every shift for the past year quit. I hope she retired to Florida and is a happy camper.

But something tells me she's looking for another night shift nursing job.

When I grow up and write nursing....

2007-01-12T15:38:00.001-08:00

I want to write it like oncRN does.
/jo

Stepdown ICU

2007-01-10T20:58:00.000-08:00

is going great. Much new things, still processing. It's a totally different ballgame. I have both earned an appreciation for what I've been doing all year in rehab, and realized how much more there is to do.

And I hate working days with a fiery passion. The people are lovely. The cardiothoracic surgeons are civil. (Which is a LOT to ask of a cardiothoracic surgeon...you may agree with me that civility is a basic right to ask of a colleague, but to have three of them all be civil to the New Nurse Even When She Pages the Wrong One At First is.... is.... unheard of.)

Day shift is utter chaos. And every time you turn around, you're feeding people. (And dietary people think it's okay to give chocolate eclairs to diabetics.) Between 830 and 900, I was supposed to assist with a thoracotomy, be an assist RN to the primary RN on a not-really-planned intubation, and yank a chest tube in ICU. (Two out of three is not shabby.)

Much to tell. Mostly, I need to sleep. Because I need to wake up in 6 hours and do it again.

I do need to go back to nights. I can just tell from the brief interactions at report time, most of them are my people. The tele tech said to me this morning, "There's something just so natural about rolling out of bed at 4p.m."

But you know what I think? I think I love my new job.

New Change of Shift

2006-12-30T11:33:00.001-08:00

is up!

T minus 1 day

2006-12-30T11:27:00.000-08:00

I start Stepdown ICU on Monday.

I'm excited, I'm nervous. I'm profoundly ready for a change.

It's what I hope nursing can be. It's the cream of the crop at my hospital, a place where all the nurses seem to be happy. It's what I hope will be a level of professionalism that I myself shoot for. I'm sure my expectations will get adjusted, but I'm also hoping they won't get adjusted as dramatically as they were in rehab.

So my coming posts will hopefully be full of fun adventures in my journey into critical care. Yay!
/jo

Nursing != kumbaya

2006-12-24T03:54:00.000-08:00

I hate cute.

I was always a kid with a dark streak. I was reading Alfred Hitchcock books when I was 11. I loved Nancy Drew, hated Barbie. My mom didn't get a girl who loved pink and lavendar, my mother was clawing at her face and moaning, "Could you PLEASE wear ANOTHER COLOR BESIDES BLACK?!?!"

I taught myself to program as a proto-teenager. Later, I chopped my blonde locks into something spiky my parents hated. Later, I went to college in a large city, studied art, smoked heavily and occasionally did illegal substances. I drank a lot of coffee. I made very large and disturbing oil paintings. Later, I translated those self-taught programming skills into my own business, and worked as a nerd for many years. I can code in 5 languages and can understand at least twice that number.

I don't smoke anymore. I stopped the drugs many years ago after an (deserved) incident with strychnine.

I became a nurse because I was at my dying grandfather's bedside. I wanted then, and still want, to ultimately be a hospice nurse. I'm more comfortable with death than with birth. The teenage dark streak was actually not rebellion, I really am creepy. But I want to do it not because I'm creepy, but because I get that dark is scary and I am not afraid to be present with somebody and provide comfort and good clinical care while they're afraid.

My point of telling you this is to say that nowhere in my life did I learn kumbaya. At no time did I ever gravitate to cute. Gender roles are not something I get.

The nursing I learned from my professors is one of clinical assessment, nursing judgement, pathophysiology and pharmacology. One of chemistry medmath and sound skills of listening and feedback grounded in clinical psych.

There are days I think I learned nursing from Betelgeuse. I don't know where that nursing is.

Too much of nursing is cute. Several people have blogged lately and railed against SpongeBob scrubs. I am in accord. I do wear patterns, Chinese coins, African masks, and Art Deco butterflies (which could be construed = cute), southwest Navajo motifs...in reds and dark purples and blues and greens. My excuse for not wearing solids is the art background. This might be a lame excuse.

I went to the Nurse Practice Council meeting for the first time last week. The love at that meeting made me feel like I was choking in a sea of cotton candy. "I want to thank SoNSo for their contribution and for..." "I want to thank you all for being here today...." "You all have done such a wonderful job with..."

We were all so busy thanking and congratulating each other, that nothing got accomplished.

I've had geek meetings that nothing gets accomplished, too. But it's "There's this problem with the code..." "This module keeps breaking...." "The customer wants this..." It may not translate to actionable items, but there's a lot less smiling sweetly and nodding and CLAPPING

...GOD...they CLAPPED that I had come to the meeting cos I said I was curious about NPC and what they're working on and wanted to see what I could do.

At a geek meeting, I'd've been saddled with the chunk of code that was written by Aramaic-speaking monkeys tripping on acid for that kind of volunteerism.

The trouble with kumbaya is that it isn't professionalism. So much huggy feely isn't discussion of how the latest clinical study could be communicated to, and implemented into the units. If we all need to be in consensus and accord, it flattens out the need for a person to drive hard up a clinical ladder for more responsibility, more autonomy, better pay, more respect.

If I, Joe Nobody, get the same vote weight at the table as the CNO...I think that's a problem. Really, I do. That woman defended her doctoral dissertation this week...who the f#ck am I next to her? If my vote and voice counts the same, doesn't that change a little bit my drive to go BE her in 10 years? Sure, I want a voice. But I'm okay with hierarchy, because my voice is still inexperienced and it's appropriate for more experience and better education to be at the steering wheel.

****

Just helped another nurse with a patient who was incontinent. "Let me help you clean up the pee-pee," she said.

...What's the solution? Wait until all the Granny Sunshines retire? What?!? Help me out here! How will we ever get intelligent professionals who WANT to be nurses when they "help clean up the pee-pee" and hug and kumbaya corn syrup all over each other...

!!

#!/bin/msh
#
read @vars /bin/rant.dat
foreach $vars
do
echo "And THIS is ANOTHER thing that makes me crazy:" $_
loop

exit 0

******
splat.... bang .....
/jo

Oh, rehab...

2006-12-24T02:06:00.000-08:00

This is a cranky and critical post.

But I'm SO ready to be off rehab.

These are retirement nurses. And their concerns (or lack thereof) make me nuts.

The new guy I'm orienting again Monday is nice. He went to nursing school 10 years ago, flunked the NCLEX, worked in retail management 10 years, studied for the NCLEX out of a book, took it and passed it. Bam! He's a nurse and he's orienting on my unit.

He didn't know he needed to have a stethoscope. Or a drug book/PDA pharm reference. He did show up wearing scrubs, though.

You, too, can be a licensed RN by studying books, I guess.

The New Guy has no practical skills. He hasn't touched a patient except for clinicals 10 years ago. He doesn't know how to take vital signs. He stands behind the patient s/p L5-S2 fusion to talk to him. It doesn't occur to him that the vomiting patient who cannot speak wants to brush her teeth after we get her cleaned up. He doesn't have the lingo....'LRE' is not how you note right lower extremity. He doesn't know where on the back to listen to lungs (I had to tell him to listen to the back), how to describe the sound ("I heard gurgling"), much less what it might mean in the total picture of the pt's dx, comorbidities, funky bicarbonate and elevated temp.

He can learn. However, I can't teach him med-surg in four shifts, much less rehab. Trouble is that in my hospital, people regard rehab = TCU. GOOD rehab is med-surg knowledge PLUS physical medicine and speech/cognitive therapy. Sadly here, people are content to have rehab being the nursing pasture.

Except that the patient acuity is changing and and it is not okay to have this the nurses' retirement home anymore. We all know patients are sicker everywhere now. Medicare is making that dramatically so in rehab, because it's pushing patients out of the hospitals and into the SNiFs unless they have complex comorbidities, or are among 13 diagnoses...most of which are neuro. We are not ortho TCU anymore.

And no matter what the Head of Education says, this is NOT an ideal place at ALL for a new nurse to start. No support at NOC, Old Guard nurses who are just NOT interested in handling this acuity, patients that can and increasingly do turn on a dime.

Don't you want your new grad with a few other nurses who know what to do in a crisis? Not an LPN of 30 years who hasn't listened to a lung sound in the past 10 of those years? You know, the LPN who infused NS c 20mEq of KCl at 755mL/hr this year? ...Cos the "pumps are tricky"...the one whose head is planted in a pillow 6 feet away from me right now.

Yeah, I want the new guy as the RN with her on a night like that. *boggle*

It's not that the guy can't learn, of course he can. He is not ready to have the training wheels ripped off in 6 weeks.

Not much I can do but pass on what I think to our manager (who is not a nurse), and go trotting off to stepdown. I guess this is how it goes.
/jo

Change of Shift is up!

2006-12-15T06:56:00.000-08:00

Over at Protect the Airway....

(And it looks really good this week...arg! that I can't dive in until Monday or so...)
/jo

Dear Santa,

2006-12-15T06:43:00.000-08:00

I want to write to you about what a good nurse I've been this year.

For example, let me tell you what a good job I did with a patient I discharged yesterday. He is an alcoholic, and he was under the influence and an doing extreme sport in our beloved Rocky Mountains. Now you may know that the Rocky Mountains are full of rocks, some of which are made of granite. My patient fell down and now he has a hard time remembering who's president.

But I did a good job with him. I kept him safe and didn't let him fall even when he was threatening to hit me if I didn't get out of his way. I gave him medications to keep him from having seizures and to keep his blood pressure in a good range so the injury didn't grow worse.

And when his caregiver, whose judgement the courts deem sound, wanted to take my patient home yesterday. But the caregiver believes the patient will be driving again in two weeks. The doctors, the nurses and all the therapists think another 2 - 3 weeks inpatient is ideal, and when the word 'driving' is floated, it is met by widened eyes. However, the MD discharged the patient and I helped get him ready. I prepared discharge paperwork and I sat with the patient and the caregiver and reviewed everything.

Now I know my patient likes to drink. And there's a medicine my patient takes that can cause him to keel over dead if he drinks while taking this medicine. I used a big fat highlighter to explain this to the patient and the caregiver. I was REALLY ADAMANT about how important this was. And when the caregiver said, "Well, what I want him to do and what he does are two different things", I did not turn into a howling banshee and hit anybody.

I documented the heck out of my teaching to the patient and caregiver like a good nurse.

So you see, Santa, I was a good nurse. What I would like most for Christmas this year is a hovercraft.

Love and homemade cookies,
/justcallmejo

How weird is it and A little about restraints

2006-12-15T00:46:00.000-08:00

...when your CNO leaves a book in your little inbox called, "Hardwiring Excellence: Purpose, Worthwhile Work, Making a Difference"...?

A book, mind you. Not a bookLET, a 280 page softcover book.

By the way, I've been busy with holidays and ...okay, that's a lie. I've been busily taking Sudafed, eating soup and quilting. Okay, SOME of the things I've been doing is shopping and wrapping presents. I want to have been busily writing cards, but I haven't.

I wanted to post a followup to what I said last time in "Babel Fish". I don't want anyone to think that I'm laughing at people with TBI. Ever. I hope it didn't sound that way. I wanted to write about restraints, actually. Another blog I pop over to, Death Maiden's place, was talking about that a few weeks ago. Some fleeting brain dump on the subject:

The patient with the Great Escape plan did just that today: he went AMA. (Against medical advice.) I hear he's "better", but if he's leaving AMA, clearly physical or occupational therapy thought there was room for hospital-based improvement, and not just outpatient.

But I have a new brain injured patient tonight. He has a posey bed (Vail bed), and I don't have it zipped up so he's not actually restrained at the moment. He's sleeping and refusing all oral medications. Fortunately a 97/63 bp means I wasn't gonna give the bp meds anyway. But there's some antipsychotics NOT floating around in his body that should be and I'm waiting for the crazy any minute.

I spent an hour tonight with his sweet wife, who tearfully tells me "He's not like this, he's a NICE PERSON." Nobody said he wasn't, regardless of how he's called each of us several expletives today. I believe her. It's part of the pathophysiology. She's 100 lbs soaking wet and saying, "If I just took him home and got him to clear from the meds, he'd be okay, right?"

No, my dear, we all want that to be true but it is not. Right now, your beloved husband is not himself and he could hurt you. He could hurt himself. What happens when he says, "Honey, I'm going to work", gets behind the wheel of a car, seizes, and kills himself and the family of 4 in the minivan he crashes? He can't walk to the bathroom by himself right now. He was demanding his car keys this morning, right before he managed to get into the elevator and wouldn't come out without the kind assistance of four security guards.

It's horrible to watch her go through this. She didn't see the episode this morning, so she doesn't *really* believe me when I tell her he was combative. He tells her to "get the fuck away from me" and she looks startled. I'm sure he has never spoken to her this way in his life. Even with that verbal slap to the face, she doesn't believe he could be violent. I tried to get the patient to open his eyes by gently rubbing his shoulder and saying "Joe Schmo, open your eyes for me please" and he balled up his fists and said, "Leave me alone or I'll fucking fight you." She heard these things, and she cannot believe it. "This is the man I love," she says with tears in her eyes. Yes. And given some time, he will come back to you. Right now, his judgement is impaired, and self-control at a low and higher cerebral function is out the window. He's operating at a bit lower on Maslow's hierarchy of needs. Hit scary strangers trying to make me put pills in my mouth first, dialogic reasoning a couple weeks later.

Did I mention he's a good 6 inches taller, a good 60 pounds heavier and substantially more muscled than me? Ergo, he's in a bed that zips up so he cannot easily get out. (I'm sure someone has managed to escape a Vail bed, I just haven't seen it yet.)

Did I ever tell you that when I was a CNA, I worked with a woman who'd had her jaw broken from a brain-injured patient?

Did I ever tell you about the time a guy threw a telephone at my coworker while we were 2:1 sitting him?

How bout the guy that swung at me for an hour, screaming at the top of his lungs that he wanted a cigarrette? (Bless some aspects of brain injury: rotten aim)

Just so you realize that I don't find restraints funny, nor are people with brain injury funny. (Except when they are.) We don't restrain people here unless we absolutely HAVE TO. We don't gork patients out on meds for fun or don't want to deal with them. But I'll be damned if I'm gonna devote my career to caring for other people and helping and DOING something real for the world...and then have one person who's confused bust my jaw cos s/he can't have a cigarrette.

On the upside: the guy with the telephone? IV Niacin cleared him up like nothing ever happened. Once out of the ICU, he came back to us just the politest, kindest, most lovely patient you could hope to have. He didn't remember any of us, didn't remember the night of the 42 blood sugar, didn't remember the night of the seizures, didn't remember the babbling and drooling and, as Laura memorably put "he's lookin like a yard sale". This was a new man.

Nobody mentioned the projectile telephone bit. He's home, doing well, back to being independent.

Anyway.

****************

I'm looking at this book and still weirded out. Why is the CNO giving me, new grad + 1 yr out RN, a ...leadership book. I'm getting Soylent Green/podpeople kind of oogies. This IS weird, right?

Babel Fish

2006-12-09T02:41:00.000-08:00

Okay, the truth is that I do enjoy working with brain injured people sometimes.

We got an admission tonight who reminds me of M, who I told many stories about few months back on livejournal. (I could repost here.) I was really fond of M. From M's condition and prognosis on arrival to where he was when he left? We made a rocket scientist out of him. And the entire team here fought tooth and nail for every inch. That crazy bastard enriched my life more than I ever did squat for him.

So tonight's admit is not even my patient, but P is stepping back a lot and letting me kind of manage him. It's been okay in this case that she wants me to take over for (yet another) patient she can't manage well because she's not pretending it's so I can "practice", I'm getting paid to be charge tonight and she actually asked for a hand tonight BEFORE something went horribly awry.

And he's nuts. Nuts in that way only the head-bonked seem to be, which is not the same as dementia or Axis I psych. He's quite friendly, and so far hasn't taken a swing at anybody. He tried to leave and we did have to do some IVP meds and he's got a posey bed, which he hates. (As you would, too.) But we're managing and he's having a fantastic night all things considered.

But he's uniquely funny in the way of someone with a TBI too. And I'm not laughing at...what I find funny is how beautifully the mind works and the connections it makes. It's like there's a layer of film of varying murkiness between some people with TBI and you...a layer that can only be crossed with a Babel Fish.

Had a patient once substitute "train" for the word "clock". Once I had that translation click through the Babel Fish, not only did I understand the patient, I felt like I got this glimpse of color about the person's life. His look was of someone who speaks a language you do not, but through charades and well-intentioned, but mangled conjugations, meaning suddenly shines through. Yes! You know what I'm saying! And to me, it felt like a deeper understanding somehow than if he'd used the proper noun.

Train. Clock. A smidge of viridian green left over from here, or an arch of charcoal over there. Color worth the work it took through translation.

So this new guy woke up at 0300 (in his poseybed) and he called out, "Can I get some help in here?" So S (CNA) gets up to go help. "....And can I get a butter knife?"

And I think of the Great Escape and somewhere I wonder if he's planning on hiding the butter knife in his sock so he can hunker down and dig his way out of his posey bed when we're not looking.

And it makes me laugh deep. Because that makes SO much sense.

And I have decided that I really like this guy and I'm looking forward to more through the Babel Fish.
/jo

Twelve more shifts of rehab

2006-12-07T03:27:00.000-08:00

...and every single one is gonna be like climbing over boulders to the summit.

With hail the size of golfballs, and not having the sense to turn around and stumble down the mountain. And the black clouds boiling just past the summit, which you can see beyond Mt. Massive, for example.

It's nice that I can speak nicely of rehab on my days off. When I'm here, I can't. I'm cranky about having to go to work from the moment I wake up and notice that my bedroom light is dimming. As always, I like my patients. I spent good time with all four. Everybody is sleeping, pain-free (as far as the snoring tells me), properly anticoagulated (strokes, THAs and TKAs), have happily percolating GI tracts, are voiding adequate amounts, and the two with stage 1 sores are being flipped q2...and a few have specimens in petri dishes to see if anything grows.

It's my colleague who isn't managing the geriatric COPD'er with the new small bowel obstruction...the woman who has been wailing and gnashing her teeth for (Jo looks at clock) nine solid hours so far.

Snippets from a real conversations....
The players:
RN of six years experience, who took this job "because it was babysitting"
Me.

Other RN: "She might need an NG tube."
Me (who, at 0200, is already reading pulp fiction being done with everything I can think of to do): "Mmm. Might."
Other RN: "Would you like to practice putting an NG in?"
Me, looking up and she's avoiding looking at me: "Considering I'm the only nurse who's put one in this year, yes, I can do it for you if you don't feel comfortable doing so yourself, OtherRN."
Other RN doesn't reply. I go back to my book.

Other RN gets the countremand order to not place it, anyway. Other RN: "I don't know why Dr. K doesn't want one when Dr. B does."
Me: "Mmmmummmummm. (I don't know.) Maybe cos she's not vomiting and she pooped today and he's coming to see her early in the morning and the Xray was preliminary and he didn't look at it himself cos he was home asleep ...and he maybe figures she's NPO now. Dunno. An NG's gonna slurp up gastric juice, it wouldn't resolve an obstruction or ileus just by having suction, would it?" I wasn't being sarcastic with her. I genuinely don't know why no NG tonight. I'm not a gastroenterologist. Maybe I'd sink one, maybe I wouldn't. Not a GI nurse, either. I don't know these things, but apparently OtherRN is having a hard time thinking that through.

....But might it have occurred to her, since the woman has been moaning and crying for (Jo looks at clock) TEN hours, to get the poor thing something for pain?

Am I just mean? I feel mean.

She called the nursing supervisor to start a peripheral IV. Before attempting it herself, and before saying, "Hey Jo, would you look at her veins?" The woman might be elderly, but she had pipes. A drunken monkey could've found a vein and poked it.

Gah!

Twelve more shifts. The vast majority of them with this nurse, too.
/jo

And I'm already dreading tomorrow, where we send two patients home and I'll have THREE tomorrow night. At least there's a NOC magnet meeting (yes, we're trying to join the club) to give me something to do for an hour. Gah.

It's only 5....

p.s. Of COURSE I *cough* suggested she ask the MD for more pain meds. Reply? "But I just gave her (insert mild narc here)." gah...

Sinus arrhythmia

Bob Brown in ICU 17

My buddy "Zack"...

Americans and their sliced cheese.

How do we do this?

A tale of two patients.

Ejection fraction of 4

The conscience clause.

Compassion...

What I wish patients would do:

Dear MD, please write some orders for me. Thanks, your friendly RN

Clinical case study du jour.

And then there's the tiny little good things...

Helping those that do not help themselves.

This is a public service anouncement

And if you didn't catch that before:

You all WILL be voting, right?

Specialty BLS

Not loving....

Client.

Good money as a nurse.

Retooling.

Breathe, dammit!

Sedate my Dad, please...

Then AFTER the sentinel event....

i need a drink.

Nurses Who Love Their Jobs.

My dumb government.

Proof of job security, #749

A rare slow night in the ICU...

Things that crack me up about Press-Ganey

Just a snapshot.

Change of Shift is up!

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

...and then there are good days.

The myopia of Dr. Surgeon.

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

I love MICU: reason #1

Sinus arrhythmia with multifocal atrial tach.

The Republican candidate....

Does that BSN really matter?

I'm back.

Beer does this.

Go read this:

Crazy old bat stole my car keys.

I loved this:

I am contagion. I called in to work. I feel no guilt.

None of our doctors seem to want to own my patients at night

Our happy health care system.

What the sick role should be

Boring hospital politics, part 17

Critical care class, weeks 1 & 2

Possibilities on the Horizon

Pissing Off the Management: a novella

Still have a pulse.

Stupid thought of the day

I guess it all starts somewhere

Roux-en-Y

Yeah, and?

An Hour in the Life

I got a thank you note!

Relocation hiatus

Travelers.

Three to one...

*my quarter-inch-long fingernails on a chalkboard*

Worth a click...

Some planets are aligned against me.

If I ran the world...

The Nurse Practice Sticker Club

I am not her big sister....

Do not tell a crazy ba$tard to "not mess with you because it's not funny."

The organized mind.

Who the heck would sue me when I'm trying to help?

No.

The big fish in the petri dish

"Someday, you'll grow up and be a dayshifter, too."

Change of Shift is up!

Things I cannot live without:

Code White

Liver failure: prelude to 'Code White'

my quarter-inch-long fingernails on a chalkboard