Friday, March 28, 2008

Full Moon

My last 4 night stretch was insane. A little recap for your reading pleasure...

Night # 1: 95%er, see this post

Night #2: Freshly extubated patient goes into respiratory distress, with sustained tachycardia and hypertension, spiking fevers, and one nasty tunneling pressure ulcer from an unclosed section of autograft, and pooping gallons of poo. (oh the glory that is my job)

Night #3:
-Upon return from the hyperbaric chamber, a smoke inhalation admission (Pt A) from night #2 drops her BP to 60/30, her heart rate beats at 185, her troponin 0.7....can we say having a massive heart attack?
-While pt A is having her heart attack, the fellow sees a lab result from another new smoke inhalation patient and realizes that the patient needs to have a STAT arterial blood gas drawn...respiratory distress, here she comes!.
-A float nurse, taking care of pt C, decides that because he isn't familiar with burns and just wont do wound care...umm., that didn't fly with the us nurses. The above metnined nurse also revealed that he doesn't know how to use an A-line...uh, okay. maybe you should have told us that before you got report, now the assignment has to be changed at 2am.
-Then arrives incareratedpt E and his chain gang guards. No one can get blood from him...nurse Kelly to the rescue...guess I was feeling like a vampire, got it on the first stick.
-Pt F, thinks it's a good time to have runs of PVC's and then go into V-tach.
-About this time the central lab calls to inform Nurse M that patient E's blood sugar is 44. Did I mention that Nurse M is also taking care of patient F? So I venture in to give some D50, but what do you know?...the patient has pulled out her IV! Okay, IV dextrose out, oral glucose gel in! I

'm sure more was going on during this time but my head really couldn't do much more.

Night #4:
-Pt A has another cardiac episode.
-2 admissions from the ER...why do people let their kids play with matches?!?!?
-Mr. A's (not to be confused with Pt A) trach balloon popped thus severely diminishing the ability for the ventilator to deliver his oxygen. What to do?!? Yup, replace it STAT at the bedside. Oh yeah, that's right, there is ah hospital wide shortage on #8 trach sets...quick, run, to another room and see if they have an extra set. Found one! Thank God it's still in the box and plastic wrap, so much for isolation precautions. Uh, nothing a little bleach wipe can't fix!
-Back to pt A. She's maxed out on pressors, we are having to doppler her pulses every 30 minutes. Uh oh, we just lost the pulses in the right lower extremity. Call the on call fellow STAT. Oh wait, don't get excited, there just wasn't enough gel on the probe. Pulse is still there, weak-but there.
-On to pt E. Her NG tube is clogged. Can't auscultate it in the stomach, can't flush it. Out it comes. In goes a new one, we think. Nope, it's in her mouth. Try again. Nope, can't hear it in the stomach. Try it again. Nope, can't flush it. Enough! Text page the resident. His response: "No way, you're kidding, right? We couldn't get one in her the other night, she has some really funky nasopharygneal anatomy. Try it one more time, then let me know." Result? By some miracles of God, I got it in. All pt E had to do was tip her head back and continuously swallow....easier said than done.
-Did I mention that while all this was going on, our tube system (just like the ones at the drive up window at the bank) was down meaning we had to call escort to deliver all of our labs and/or send a nurse down to pharmacy to sign for meds and narcotics.

Again, I'm sure more was going on, but let's face it...we were already dealing with enough.

I wish I could say that I went home to bed, but I did not. Instead I hauled my tush across town to catch a 9:30 train to Philly to hang out with my favorite 2 and 4 year olds (R & J) for the week. Naps just weren't in the cards for R& J on Monday (who could blame them, Nurse Miss Kelly was in town!), so neither was a nap for me; however, when I finally crawled into bed at 8:45 pm after 32 hours of being awake, I was asleep in less than a minute, and it was pure bliss.

Back to work tonight. Wish me luck.

Wednesday, March 26, 2008


#1. What’s your favorite form of potatoes?

Sweet potatoes. I shared a recipe for their yummy delight a few weeks ago

#2. Pie crust. Premade or from scratch?

From scratch. Yup, typical type A over-acheiver.

#3. Vegetables. Fresh, frozen or canned?

Fresh always/as much as possible, oh how I love the farmers market;
Frozen for things like Trader Joe's white corn;
Canned never. Too much salt, too much mush.

#4. What one dish do you wish you could prepare better?

Brownies. No, I'm serious. Mine are always runny or burt to a crisp and look like little turds. Doesn't matter if they are boxed or from scratch, they always have some issue. Hmm...maybe it's my oven?

CLick on over to Valmg's blog if you want to join in the fun!

Friday, March 21, 2008


I was on vacation from work for 15 days. IT WAS HEAVEN. But all good things must come to and end, right? Um, yeah, they do.

Last night was my first night back. As I got off the elevator the familiar, "welcoming" smell of cauterized flesh, charred skin, and topical antimicrobicals wafted under my nose. Sigh...

I went to the scrubex, got my scrubs, punched in, and headed into the locker room. I almost forgot my combination, but it soon came to me. I chatted with my fellow coworkers who were interested in hearing about my vacation and then I ventured out to "face my doom." To my surprise, staffing was okay, I had two relatively stable patients, well minus the ventilator and erratic junctional rhythm that plagued my patients on top of their burns. I no sooner finished getting report, when the charge nurse hung up the phone and paged me. "Don't get report, Kelly. We're changing the assignment, We've on 80%er." Eeks. Although I love the adrenaline rush of big, fresh, juicy burn, the anticipation can be overwhelming. I tried to get more of the history, but we didn't have a lot of information. the patient was being seen by the fellow and resident down in the ER, the ER nurse was going to be calling up report, but I needed to move fast and set up for a long night ahead.

As that thought crossed my mind, my stomach gave me a little rumble. Guess I should have eaten those eggs I hard boiled at home.

I set off to the supply room in a fury..gathering all my supplies, setting up central lines, prepping for an arterial line, anticipating the needs for a salem sump nasogastic tube insertion, finding all of the supplies to do burn care, paging respiratory to bring me a ventilator, etc. My hands were full, my heart beat was quick, my steps rapid. Game on folks!

I no sooner had everything set up, when the ER called up. I took report. 88 year old female with 95% TBSA (total body surface area) 3rd degree burns-yikes, worse than I thought. Pt was intubated in the ER and currently having an A-line placed. Vitals signs, not so stable; Respiratory status, shitty;core body temperature, 31.1 (that's88 degree Fahrenheit); chance of survival, less than 2 percent. She'd be arriving on the floor in 15 minutes.

Exactly 15 minutes later (shocker, I know! ER time estimates are never accurate) my patient arrived via stretcher being bagged by the respiratory therapist, attached to the portable cardiac monitor, and accompanied by one of our burn fellows. Hmm, gotta love that smell. Charred flesh, and lots of it. Immediately, we transferred her to the bed, hooked up all her lines, started a versed drip, continued to pump her with her Parkland Burn Formula fluid requirements (22Liters in 24 hours. Her temperature 31 degrees. With each degree that her body temperature dropped, so does her chance of survival. WE ran all her fluids though the fluid warmer, placed her under the heat shield and bair hugger. Building engineering increased the temperature of her room to 80 degrees....thank god I remembered my deodorant!
This poor woman was a mess. Her extremities were like icicles to the the touch, her skin beginning to swell as we pump her massively vasodilated circulatory system with fluids, her blood pressure remained low, her heart rate high...all signs pointing to being intravascularly depleted and dry. We couldn't do burn care, she was too cold.

The woman had no family, but her power of attorney was on her way in from New Jersey with the patients living will. Until then, we just had to wait. I ran around hanging fluids, pushing meds, sending of arterial blood gases and blood work, but she wasn't warming up. I sent off her blood to get a metabolic profile with all her electrolytes, but she was so cold and vasoconstricted that the blood kept hemolyzing and we couldn't get a reading. I thought attempt #4 would be my lucky shot, but I no sooner sent off her labs, than I got a phone call from the lab that the top popped off and the sample was lost. What the hell?!?! I can't keep drawing blood off this patient, she's not stable enough for the circus. I gave it one more shot, finally success.

As I was finishing the priest came to administer last rites, the patients last request before she was intubated. Yes, that's right. She was awake and alert for almost 2 1/2 hours. As the priest prayer with/over the now sedated and vented patient, I felt calmed, like if the woman was to die (on this Good Friday) that she would be at a spiritual peace. After the priest left, 3 different neighbors came to pray the Rosary over her. I was touched.

At 1am the health care proxy/power of attorney arrived, looking shaken and upset. I went with the fellow and we gently talked with the woman outside the room. After calling the administrator on call and the attending, the patient was made DNR with no escalation of care. I sat with the HCP (turns out she's the patients god-daughter) and let her know that I would continue to remain available to them if she had questions or needs over night. She thanked me and left.

By 4am, the woman had only put out 4 cc's of black turbid "urine". Quick little bit of math for you: 15 Liters (15,000cc) of fluid in, 4cc out, = 14996net. Kidneys have shut down.

Around 5am her respiratory status really started to decline. Her lungs were filling with fluid and her circumferential chest burns weren't allowing her lungs and chest wall to expand. Aside from changing a few settings on the vent to force some of the alveloi open, there wasn't much we could go. The waiting game began.
Soon to follow, her blood pressure took a hit and her heart rate continued to rise. She wasn't perfusing her extremities. She was loosing body heat again.My heart sank. I stood there and said a quick prayer.

By change of shift, her prognosis was grim and it was torture giving report to the say nurse. It was futile. I felt like I was handing over a corpse. As I walked off the unit Friday morning, I wondered what the day would bring for my dear patient. I went home exhausted. I realized that I hadn't been to the bathroom in 13 hours, but then again I hadn't drank anything either...and that's why my urine was almost the color of tea. Sorry if that's TMI.

Despite the exhaustion, I couldn't sleep. I tossed and turned. Around 1:30 I got up and went running. It was good to clear my head, I needed that.

As I walked back onto the floor Friday night, I heard the overhead page. "Nurse taking care of pt in room XXX please indicate. Transport is here."

And so it happened. She died. The day nurse reported to me that the family decided to withdraw care and remove the patient from the ventilator around 4:XXp.m. She died 8 minutes later.

I'm not sure if it was because this is Holy Week, or because it was my first night back after a glorious vacation, but I do know that Thursday night affected me. We need to cherish each and every day because the only guarantee in life is that there are no guarantees.

Wednesday, March 19, 2008

Mail Call

I'll admit it. I've bought into the "Go Green" rah-rah commotion. Actually, I know this sounds dorky, but it's so satisfying to recycle. Growing up in the suburbs, we always recycled. In fact, if I sorted the cans and bottles, and helped bring them to the redemption center, my parents used to let me keep the money. Hey, when you are a kid, $5 is "a lotta" money.

A few weeks ago, I went out an bought these two super cute tall rattan baskets with for paper, one for plastic. Now that I don't drink soda, and avoid high sodium canned food, rarely is there any aluminum in our apartment. Since purchasing the baskets, we have much less garbage. Maybe 1 bag every 5 days-and that's only after we combine the bathroom and our bedroom trash cans. Go us!

Where was I going with this? Oh yeah. In college, where I became an email/computer/facebook slut, I started doing all my banking and bill paying online. It greatly reduced the amount of mail I received. I also stopped requesting catalogues and would strictly look at the goods online. Seems like a good idea, right? However, the one thing that never seemed to cease was the credit card offers. I cannot tell you how many mailings I would get weekly offering me the "best APR" around, 0% financing, "No fees for 1 year". It's insanity people. Did I mention that the offers come addressed to the most ludicrous names? Kessy Seller-Kelley Seffler-Kally Sesfler, come on people! If you are going to tempt me, at least get my name correct! I only have 1 credit card, thankyouverymuch, and I am quite content with it. I pay my bill each month, never carry a balance, and get pretty decent rewards with it. Wait, I'm getting off topic again. Sorry.

Back on track. Again. Okay, ready, set, go! Junk mail. I thought I was being so smart and taking advantage of the online options, but suddenly I find my email inbox filled with unsolicited emails, clearly my address was just sold and spammed out over the net. For a while I was replying to the "Unsubscribe" feature, but useless, the spam kept coming, even through my spam filter. It's not so much that I mind the occasional junk offer, but I'm contemplating going wireless with a blackberry (gasp! she's becoming a true "New Yorker") and I don't want to get all riled up with new emails only to be let down realizing it's another "Free sample of Viage" email.

I decided to end this email nonsense today. Especially after returning from my vacation to over 250 emails, most of which were SPAM-A-LISCIOUS. After a trusty google search, I came across this website, Direct Marketing Association. It gives plenty of suggestion for how to cut down on junk mail/emails . Click here to join DMA’s eMail Preference Service (eMPS that ) allows consumers to indicate their wish to reduce the amount of unsolicited commercial email they receive. I joined, and if you like, you should too!

Feeling satisfied with my accomplishments, I sought out some more information on recycling and "Going Green" in New York. I was happily surprised to come across the New York "Wastele$$" website. Check it out, it has some really useful tips, even if you don't live in NY.

I guess I can get off my soapbox now, I feel satisfied. The end.

Tuesday, March 18, 2008

Late But Not Lost

Even though I was away in Paradise (sigh....) here's my FFOF entry for last week....

#1. What’s your favorite fruit and how do you like to eat it?
Summer- Watermelon, cold and cubed
Winter-Oranges, much needed vitamin C
Spring- Grapes, juicy and sweet
Fall- Apples! I'll always be a New Eng lander at heart

#2. What is the one spice in your kitchen you use more than any other?
Garlic. Good for your cholesterol, even better for date night, haha!

#3. Pudding. Instant, stove top or premade?
Hmmm, I guess a twist on instant. I add plain yogurt. I'd add my "milk", but the box specifically says, "DO NOT USE SOY MILK". I tried ignoring this warning once, mission failed.

#4. Share a recipe using potatoes.
I make these whenever having a dinner party...there are never any leftovers!

3 Russet Potatoes
1/2 cup Parmesan Cheese
2 TB garlic salt
1 TB Black Pepper
1TB dried rosemary (use less if using ground)
1 1/2 TB dried minced onion
1/4 cup extra virgin olive oil

Preheat oven to 450
Wash outside of potatoes
Chop and cube (1/2 inch)

Mix garlic, pepper. onion in small bowl, set aside

Place cubes in large bowl, drizzle just EVOO over top and lightly coat (may not need all the oil); toss with fingers; sprinkle salt mixture over cubes; toss again

Spread cubes over 2 baking sheets
Sprinkle 1/4 of Parmesan cheese over cubes
Place in oven; check in 15 minutes-flip, sprinkle more cheese; check in 10 minutes, flip, sprinkle; place back in oven until golden brown.
Upon removal, coat with remainder of cheese.

Serve warm!

As always, to join the meme, check out Valmg's blog

Monday, March 17, 2008

I'm back!!!!

Just in case you all were wondering, I'm back. Fully refreshed and recharged! Ready to work (well, maybe). I've got a post coming with all the details of my 8 days in paradise, so bear with me. On a different note, Happy Saint Patrick's Day!

Thursday, March 06, 2008

Four Foods on Friday; Sensing the trend?

Here are this week’s four questions.

#1. What type of m&m is your favorite?
Peanut Butter. If you are going to be bad, why not indulge?

#2. Peanut butter. Smooth, chunky, creamy. How do you like it?

All natural and extra chunky; Teddy Brand

#3. Do you usually drink out of glass, acrylic, Tupperware type or paper cups?

Tacky plastic souvenir cups at home; my nalgene (acrylic?) water bottle at the gym and work.

#4. Share a chicken recipe. I cooked this for my gramps one day last summer...he still asks about it. It's from the whole foods recipe series

Balsamic Marinated Chicken served with Grilled Peaches, Sweet Onions & Rosemary
Skinless chicken breasts, marinated in balsamic vinegar and maple syrup, are grilled along with sweet onions and halved peaches, all crowned with fresh rosemary. Delicious.

Serves 6
3 whole skinless, boneless chicken breasts, split
2 tablespoons balsamic vinegar
1 tablespoon maple syrup
4 tablespoons olive oil
1 teaspoon salt
1/4 teaspoon ground black pepper
6 ripe, firm peaches, cut in half, pit removed
2 large sweet onions, cut into 1/4-inch thick rings
4 tablespoons orange juice
2 tablespoons olive oil
2 tablespoons finely chopped fresh rosemary plus 6 sprigs for garnish
salt to taste
Rinse and pat chicken breasts dry. Place in a large mixing bowl. Combine the balsamic vinegar, maple syrup, olive oil, salt and pepper and pour over chicken. Turn pieces of chicken to coat thoroughly with marinade. Cover tightly and refrigerate for at least 2 hours or overnight. Turn chicken several times.

Prepare a charcoal grill or heat a gas grill to medium-high heat. Toss peaches and onion rings with orange juice, olive oil and rosemary. Season with salt to taste. Remove chicken from marinade and grill about 5 minutes per side, until cooked through. Grill peaches and onions until tender and slightly charred. Serve chicken with peach halves and generously top with grilled onions. Garnish each portion with fresh rosemary sprig.

If you want to join, go here! The more the merrier :)

Tuesday, March 04, 2008

watch what you write

In the medical world, charting and documentation dominates.

From a legal standpoint, proper charting could save your but if you go to get sued, improper/sloppy/half asses charting pretty much asks the plaintiff" How much is this going to cost me?"

From a medical standpoint, the entire point of charting is to be communicative and objective to the rest of the medical team, i.e. make sure everyone is on the same page with access to the same information to make informed decisisons regarding patient care.

We are all guilty of some type of "bad charting" (oh God, I am the QUEEN of spelling errors), but here are a few examples of what you don't want to be caught charting (unless, that is, you enjoy being laughed at by your co-workers/everyone who reads this blog entry/anyone who read the original posting....


1. She has no rigors or shaking chills , but her husband states she
was very hot in bed last night.

2. Patient has chest pain if she lies on her left side for over a year.

3. On the second day the knee was better, and on the third day it disappeared.

4. The patient is tearful and crying constantly. She also appears to be depressed.

5. The patient has been depressed since she began seeing me in 1993.

6. Discharge status: Alive but without my permission.

7. Healthy appearing decrepit 69 year old male, mentally alert but forgetful.

8. The patient refused autopsy.

9. The patient has no previous history of suicides.

10. Patient has left white blood cells at another hospital.

11. Patent's medical history has been remarkably insignificant with only a 40 pound
weight gain in the past three days.

12. Patient had waffles for breakfast and anorexia for lunch.

13. Between you and me, we ought to be able to get this lady pregnant.

14. Since she can't get pregnant with her husband, I thought you might like to
work her up.

15. She is numb from her toes down.

16. While in ER, she was examined, X-rated and sent home.

17. The skin was moist and dry.

18. Occasional, constant infrequent headaches.

19. Patient was alert and unresponsive.

20. Rectal examination revealed a normal size thyroid.

21. She stated that she had been constipated for most of her life, until she got
a divorce.

22. I saw your patient today, who is still under our car for physical therapy.

23. Both breasts are equal and reactive to light and accommodation.

24. Examination of genitalia reveals that he is circus sized.

25. The lab test indicated abnormal lover function.

26. The patient was to have a bowel resection. However, he took a job as a stock
broker instead.

27. Skin: somewhat pale but present.

28. The pelvic exam will be done later on the floor.

29. Patient was seen in consultation by Dr. Blank, who felt we should sit on the
abdomen and I agree.

30. Large brown stool ambulating in the hall.

31. Patient has two teenage children, but no other abnormalities.

Hope this made you smile. Now, type on fellow bloggers, type on! (utilizing spell check of course!)

Saturday, March 01, 2008

Never a Dull Moment

Get to work 15 minutes early to do some is locked.

Go to scrub dispenser...out of smalls...I'm sporting the Jared from Subway "after" look tonight

Get report on my patients...hear the assignment was changed...get new report...assignment changed back...I'm utterly confused

Begin dressing changes and burn care...finish...begin charting

Charting interrupted by on call resident...I'm getting an admission...set up the room

ER calls up to give report, hangs up before I come to the phone, I call back, they tell me they are too busy to give report....right! and I've got nothing but time?!?!

Go back to finish charting..."Terminal System Error"...all my charting, GONE! POOF! Bye-Bye!

ER calls, gives me report, chews me out for delaying the transfer....uhhh, weren't you the one too busy to take my phone call?

Pt arrives on the floor, parents refusing NG tube and enteral supplements, mom whips out breast and tells me, "THIS is what MY kid will eat"

Initial wound management, skin removal, debridement, etc....

30 Minute discussion (calm and collected) about the inflammatory response and hyper metabolic state s/p burn injuries...father finally agrees to supplements...Mom and dad apologize for being edgy

Back to the lost charting...30 minutes on the phone with IT...they are useless I tell ya!

Charting..."Quick! somebody help me! Now, come soon!"...L and I leap from our seats and see the crazy (no, she is actually certifiable) lady in room *** naked, half out of bed, with all her pumps alarming and chining, tubing disconnected, her wounded extremity thrown over the side of the bed, and urine everywhere...babbling nonsensically...IV Haldol? Yup, think that's just what the doctor ordered!

But wait! What's that noise? Oh yes, the fire alarm. All doors need to closed, pt's and/or their family members sticking their heads out the doors, asking us to turn off the noise...sorry folks, I know a 4am fire alarm isn't really convenient for your sleep, but think about the poor buggers it's actually affecting...oh wait, they just announced, someone was smoking on the 12th floor. Hey pal, thanks, no really- thanks. Jerk!

"Cardiac Team 5 North, Cardiac Team 5 North"...nothing like a 4am code. Thank God we run our own codes (one of the many joys of being an ICU nurse).

Uh-oh, lady is getting naked again...lights still flashing from the "fire" on the 12th floor...pumps beeping...pants falling down...charting mounting...patients coding....

All in a day's (I mean night's) work, right?