I've now been a nurse for a little over two years. There were times when I wanted to quit, run away, and get a cushy job (like a M-F 9 to 5 gig) but Sucked it, put my big panties on, and stuck it out. I'm glad I did. As of late, my role is much more than "just a nurse"-some of which I like, others not so much.
1. I'm a preceptor . The nurse managers and the nurse educator approached me, and said that there was a particular new grad who was really struggling with time management and attention to details. They thought that I would be the perfect preceptor for her because I'm not only efficient and organized, but I'm also calm and patient. At first I was flattered, but once I met my little "project" I really wished I wasn't so anal retentive and organized. I struggle with how disorganized and flaky she acts, but I never raise my voice. I constantly have to focus her and prompt her to prioritize patient needs. She is making small strides, but progress none the less. If nothing else, I've learned a lot about my self.
2. I was recommended by my managers to become a senior staff nurse. My application, performance improvement project, committee involvement, and inservice lesson plans are being submitted on Tuesday.
3. I advocate for my patients no matter what.
I called for a palliative care consult on a patient with lung cancer that metastasized to the bone and brain who subsequently sustained 3rd burns to 65% of her body. The resident told me that I had no night to go over the burn services authority. I pulled up the policy on WHO can make a palliative care referral and under What grounds. Guess who was right? Me. The family thanked me and the attending said on rounds, this consult was a smart idea.
4. My coworkers asked me if I would be interested in being a permanent charge nurse. Dear friends,< that would have to be a big pay raise hell no!
Life may be crazy. but I wouldn't give it up for anything.
Showing posts with label work. Show all posts
Showing posts with label work. Show all posts
Saturday, August 29, 2009
Monday, August 17, 2009
Informed Consent
So much of the healthcare world revolves around informed consent. Hospitals consider informed consent part of their best customer service, but essentially IC is a right. Patient and their families always need to be informed. But what about their health care providers? There was so much that nursing school didn't inform me about being a nurse. Sure nursing school taught me about anatomy, physiology, pharmacology, and ethics, but there's a lot that was never brought to my attention...
That patient's will test your patience.
That being able to identify a specific bateria by it's smell isn't a skil that makes you more attractive to the opposite sex.
That just because I'm comfortable talking about bodily functions, doesn't mean that it's appropraite dinner conversation
That Id both feel and hear ribs crack when I performed CPR but have to keep going
That I'd be so tired after a thirteen hour shift the thought of walking home five blocks makes mewant to cry contemplate taking a cab
That my feet and ankles would swell so much flip flops are the only comfortable shoes to wear after work
That I'd have spider veins by the time I was 25
That I'd be verbally abused my patients and their families
That I wouldn't sleep more than 3 hours inbetween my 12+ hour night shifts
That Uncle Sam would take almost half my paycheck
That money in the bank is no good when you don't have the time to enjoy it.
That I'd only get to spend one holiday with my family over a two year period
That I'd be exposed to lethal infections on a daily basis
That prophylactic antiretrolvirals following a needlestick injury would keep me in the bathroom for the better part of a month.
That doctors and nurses don't have sex in the suppy room. They have it in the on call room (kidding)
That I'd have to fight with the doctors when advocating for my patients
Looking back, if they had shoved a paper in my face and told me everything that being a nurse entails, I think I would have paused, thought about and signed anyways. Becuase even though nursing school didn't teach me any of they above, they also din't teach me...
How amzing it is to deliver a baby on the side of the FDR highway while doing a shift with the paramedics.
How gratifying it is when a patient says "Thank you for being you."
How satisfying it is to successfully run a code
How phenomenal it is to see some one survive after being burned on 90% of their body
How special it feels to be the first one a patient sees when they wake up from a coma
How nice it feels when a doctor says they are happy to have you caring for their patient
How awe inspiring it is to see a person walk on two prosthetic legs for the first time
How fulfilling it is to come home, exhausted after your shift, and know that you made a difference
That patient's will test your patience.
That being able to identify a specific bateria by it's smell isn't a skil that makes you more attractive to the opposite sex.
That just because I'm comfortable talking about bodily functions, doesn't mean that it's appropraite dinner conversation
That Id both feel and hear ribs crack when I performed CPR but have to keep going
That I'd be so tired after a thirteen hour shift the thought of walking home five blocks makes me
That my feet and ankles would swell so much flip flops are the only comfortable shoes to wear after work
That I'd have spider veins by the time I was 25
That I'd be verbally abused my patients and their families
That I wouldn't sleep more than 3 hours inbetween my 12+ hour night shifts
That Uncle Sam would take almost half my paycheck
That money in the bank is no good when you don't have the time to enjoy it.
That I'd only get to spend one holiday with my family over a two year period
That I'd be exposed to lethal infections on a daily basis
That prophylactic antiretrolvirals following a needlestick injury would keep me in the bathroom for the better part of a month.
That doctors and nurses don't have sex in the suppy room. They have it in the on call room (kidding)
That I'd have to fight with the doctors when advocating for my patients
Looking back, if they had shoved a paper in my face and told me everything that being a nurse entails, I think I would have paused, thought about and signed anyways. Becuase even though nursing school didn't teach me any of they above, they also din't teach me...
How amzing it is to deliver a baby on the side of the FDR highway while doing a shift with the paramedics.
How gratifying it is when a patient says "Thank you for being you."
How satisfying it is to successfully run a code
How phenomenal it is to see some one survive after being burned on 90% of their body
How special it feels to be the first one a patient sees when they wake up from a coma
How nice it feels when a doctor says they are happy to have you caring for their patient
How awe inspiring it is to see a person walk on two prosthetic legs for the first time
How fulfilling it is to come home, exhausted after your shift, and know that you made a difference
Thursday, June 04, 2009
When Futility Wins
We got a notification at 9am on Thursday morning that a Jane Doe, approximately 60 years old, found down at the scene with 90% TBSA burns was being transferred. We set up the room, the ventilator, the pumps, etc, and then we waited. Four hours passed before we heard anything else. We assumed that the patient didn't make it, as it was reported that the other person in the fire was pronounced dead on the scene. However, at 1pm, EMS called and said they would be there in 15 minutes. We gowned up and organized ourselves.
As the trauma elevators opened, the smell of charred flesh filled the corridor. We listened intently as the paramedics gave us report. Turns out the patient had been identified by neighbors and was not 60 years old, but rather in her late 20's. The dead person at the scene was her mother. To make matters worse, the patient had Cerebral Palsy (CP) , an uncontrolled seizure disorder, and the cognitive function of a middle schooler. Her mother was her primary caretaker. It's always hard to deal with breaking the news of loved one's death, but when there is a cognitive delay and/or deficit it's even harder. Thankfully, as crass it it sounds, this patient was unconscious and we didn't need to tell her yet.
Upon arrival her vital signs were stable, but she quickly decompensated. We placed an arterial line to monitor her blood pressure, a central line with cordis for venous access, and a SWAN to monitor her hemodyamic stability. Her blood pressures plummeted, despite liters of fluid. Her oxygenation dropped due to an inhalation injury. She was cold, 34.0 Celsius, despite fluid warmers, a heat shield, and a bair hugger. Her coags were out of control, INR = 2.6, and we were pretty sure she was in DIC. We lost pulses in her bilateral upper extremities and performed escharotomies at the bedside. She became anuric (stopped making urine), her bladder pressure soared to 35, and we opened up her belly at the bedside.
The first 24 hours were tenuous. Administer blood products- give fluids- check labs, check ABG's-adjust the ventilator. We were fighting a loosing battle. We were able to contact the family, maternal aunt, uncle, cousins, etc. They sat vigil at the bedside, but knew were this was going. They made the patient DNR. Many people not in the health care field are scared of DNR's. They think that's the equivalent of "puling the plug" or removing life support, but they are wrong. DNR- on a already intubated patient, simply means that if the heart should stop, no CPR would be given.
By Saturday afternoon, the patients' prognosis was dismal at best. Given her % burn, her lung injury, her preexisting conditions, and hemodynamic status her survival rate was less than one percent. The family listened as the doctors and nurses talked. When I came on shift that night, the aunt pulled me aside and said, "It's not good, is it? I just want her to be comfortable. She wouldn't want to live like this..."
I hate these moments. I looked at her and said, "She's sick, very sick. Even if she were to survive the next day or so, she'll never be the same. She has no skin and will likely develop an infection. We don't know how much damage her brain suffered when she was unconscious at the scene. She is currently maxed out on medications to sustain her blood pressure. We have no other options."
And then she made the toughest decision of her life. She decided that she wanted to withdraw care. However, it was not quite that simple. She wasn't the patient's health care proxy, so we needed to have two attending physicians write notes of medical futility and get approval from the administrator on call. There was nothing we could do but wait. Until that paper was approved, signed, and placed in the chart, we had to keep treating her. Around 5:30 am as the sun was rising and the sunlight was streaming into her room, her heart rate slowly began to drop; her blood pressure soon followed. When she didn't respond to any medication, a few of us nurses went in and sat with the patient at her bedside. She had no family there, but we talked to her offering words of comfort. We told her it was okay to go, that her mom was waiting for her. We talked, and talked, and talked. I swear she heard us. At 6:05 am she passed away.
As hard as it is to see someone so young die, it's even harder to think about ethics behind medical futility .
Wednesday, April 08, 2009
i've heard it all
No big surprise, our ICU census was full last night- all 20 beds occupied. Our step-down unit was only 3/4 full- 15 beds occupied. So when we got the EMS phone call at 3 am that we were getting three smoke inhalations, guess what?!?!, our three "stable" ICU patients (non vented/demented/etc) needed to head to the step-down unit.
Our prospcects were grim..
- two vneted patients over the age of 90
-two patients on CCVHD, also vented-duh!
-one fresh 30% degloving injury with history of dementia
-one 60% deglving injury, vented, in DIC
-new purpura syndrome admission with GI bleed
-fresh post op of STSG to bilateral legs on heparin gtt for a PE
-fresh extubation with signs of anoxic brain injury from initial carboxy hemoglobin > 50
-quadriplegic wound management patient with a 12% ejection fraction (systolic heart failure, ya think?!?!?)
-etc, etc,
And just who were the lucky three???
1. Thitry something year old man who refused to leave his room stating that it was Passover and that he had hired a cleaning service to come in and purify the room and it's air. Nope, under no circumstance would he leave his room to be sent to a "dirty and unholy hell hole" -direct quote.
2. Middle aged man with severe MR that likes to streak in the hallways and jump up and down naked when moaning and screaming when we do his burn care. Oh yeah, you can forget going near him with a needle for labs, let alone for IV placement...too bad he is going to the OR today for surgery.
3. Older woman with extensive history of ETOH, only 6 hours past the threshold for severe DT's. Did I mention she's obese and refuses to wear bipap so she essentially goes apnec every two minutes.
So glad that shift is over! Never a dull moment.
Our prospcects were grim..
- two vneted patients over the age of 90
-two patients on CCVHD, also vented-duh!
-one fresh 30% degloving injury with history of dementia
-one 60% deglving injury, vented, in DIC
-new purpura syndrome admission with GI bleed
-fresh post op of STSG to bilateral legs on heparin gtt for a PE
-fresh extubation with signs of anoxic brain injury from initial carboxy hemoglobin > 50
-quadriplegic wound management patient with a 12% ejection fraction (systolic heart failure, ya think?!?!?)
-etc, etc,
And just who were the lucky three???
1. Thitry something year old man who refused to leave his room stating that it was Passover and that he had hired a cleaning service to come in and purify the room and it's air. Nope, under no circumstance would he leave his room to be sent to a "dirty and unholy hell hole" -direct quote.
2. Middle aged man with severe MR that likes to streak in the hallways and jump up and down naked when moaning and screaming when we do his burn care. Oh yeah, you can forget going near him with a needle for labs, let alone for IV placement...too bad he is going to the OR today for surgery.
3. Older woman with extensive history of ETOH, only 6 hours past the threshold for severe DT's. Did I mention she's obese and refuses to wear bipap so she essentially goes apnec every two minutes.
So glad that shift is over! Never a dull moment.
Friday, February 13, 2009
Waiting on His Steps
A moment.
A bad accident.
A very tragic injury.
A young life changed forever.
A broken family grasping for hope.
But what can we do for them?
Will faith conquer impending death?
Does modern medicine prevail?
Believe in God?
They do.
To trust.
They must believe.
We will try everything.
It is a long road.
One that many do not survive.
But they sit at bedside vigil.
And sing against the tune
Of the musical alarms.
She will live.
They pray.
We hope.
Our actions suffice
And instincts are wrong
But fear lingers ever present.
Each day brings a new change.
But no more can be done.
We join in their prayer.
Medicine is not God.
We know this.
Trust him.
-KS 2009
I'm not an overly religious person, but lately I've been rocked back into my faith. Life is precious.
A bad accident.
A very tragic injury.
A young life changed forever.
A broken family grasping for hope.
But what can we do for them?
Will faith conquer impending death?
Does modern medicine prevail?
Believe in God?
They do.
To trust.
They must believe.
We will try everything.
It is a long road.
One that many do not survive.
But they sit at bedside vigil.
And sing against the tune
Of the musical alarms.
She will live.
They pray.
We hope.
Our actions suffice
And instincts are wrong
But fear lingers ever present.
Each day brings a new change.
But no more can be done.
We join in their prayer.
Medicine is not God.
We know this.
Trust him.
-KS 2009
I'm not an overly religious person, but lately I've been rocked back into my faith. Life is precious.
Wednesday, February 04, 2009
I've worked the last six nights straight.
i had to stay 5 hours late on my last morning becuase a nurse didn't show.
two nights with sickest patient on the unit, four nights as charge nurse
bed census: full! (40 patients)
toal work hours = 82
total sleep hours =24
work to sleep ratio: > 3:1
my eyes are puffy
my ankles are swollen
i have no clean underwear
my refrigerator contents: ketchup, soy sauce, applesauce, soymilk, beer
number of unanswered emails: 35
number of times I've seen my roomate in the last week: 1
my neighbors upon seeing me in the elevator: "Ouh, rough night?"
what I want to do most? sleep
what am I going to do? sleep
why am I still typing this? who knows, goodnight!
ZzZZzzZZZzzzZZZZzzzzZZZZZzzzzzZZZZzzzzZZZzzzZZzzZz
i had to stay 5 hours late on my last morning becuase a nurse didn't show.
two nights with sickest patient on the unit, four nights as charge nurse
bed census: full! (40 patients)
toal work hours = 82
total sleep hours =24
work to sleep ratio: > 3:1
my eyes are puffy
my ankles are swollen
i have no clean underwear
my refrigerator contents: ketchup, soy sauce, applesauce, soymilk, beer
number of unanswered emails: 35
number of times I've seen my roomate in the last week: 1
my neighbors upon seeing me in the elevator: "Ouh, rough night?"
what I want to do most? sleep
what am I going to do? sleep
why am I still typing this? who knows, goodnight!
ZzZZzzZZZzzzZZZZzzzzZZZZZzzzzzZZZZzzzzZZZzzzZZzzZz
Tuesday, January 13, 2009
One Final Prayer
My last two shifts were non stop, but they are two shifts that I will never forgot.
X was accepted as in international transfer five weeks post burn. Although I've seen many patients with his % burn survive, the fact that at five weeks out none of his wounds were closed was not favorable. When X finally arrived in New York at the beginning of December, he was in renal failure, maxed on dopamine and norepinepherine for his blood pressure, thrombocytopenic, in respiratory failure and ventilator dependent, and in septic shock. Additionally a MRI of his brain revealed an acute cerebellar infarct. He had six surgeries for debridment and skin grafting but none of them took as his body was invaded with fungus and bacteria. I took care of him the better half of the last two weeks and grew to know his family well. They halted their lives abroad and moved here to keep vigil at his side. They waited and prayed and waited and prayed and waited and waited and waited and prayed.
In the last two weeks, X grew sicker and sicker. He had showed some signs of improvement early on (return of some kidney function with oliguric output, improved ABG's, improved coagulation, fewer bacteria invading his wounds) but he took a turn for the worst...
Pseudomonas in the sputum, blood, and urine.
Acetinobacter in the sputum.
Candida on the skin and in the blood.
Thrombocytopenia
ARDS
Pulmonary Edema
Acute Renal Failure
Collapsed Lung
Sepsis
Acidosis
20 kilos of fluid overload with edema making him unrecognizable
In those 25 hours of work I administered 8 units of blood, 8 units of FFP, 10 units of platelets but he remained thrombocytopenic.
The ventilator was on 100%FiO2 and he was still lethally acidotic.
He required continuous deep lavage suctioning that involved removing him from the ventilator and breaking PEEP causing his blood pressure to plummet.
He was so unstable we couldn't turn him to put him on dry sheets, yet he was putting out 11 liters a day in bed drainage (yes, we suction and measure this).
He was two days overdue for day #5 post-operative dressing (POD) change.
His eyes were dilated and minimally responsive.
He was maxed out on Dopamine, Levophed, Neosenepherine, and Epinephrine.
I arrived at work on Monday and was partially surprised to find X still alive. The three hours prior to my arrival his blood pressure was resting around 68/40, his heart rate tachycardic in the 110's, and his O2 sat around 73%. The attending physicians held a discussion with the family during the day and I thought they were leading in favor of DNR, but in a desperate twist of fate the father disagreed and said he wanted "every thing possible" to be done.
During the day, the family had kept vigil at the bedside, never more than three visitors at a time. In the middle of report from the day nurse, Xs alarms sounded, his O2 sat was 65%, he needed to suctioned. The day nurse (J) and I went in and prepared to suction. We no sooner finished when his heart rate began to plummet: 110-90-80-75-70-60-55......
J yelled to get some atropine began bagging the patient. I hopped up to begin compressions. In rolled the code cart and so began the code. His venous access lines ( a right internal jugular TLC, a left femoral TLC, and left femoral Aline) were a mass of "spaghetti" coming from the 13 pumps running on either side of his bed; however, when the atropine arrived J started pushing meds, I continued compressions ,and the fellow took over bagging. I felt ribs snap, I saw my artificial compression "V-tach" heart rate on the monitor, my triceps and deltoids tightening with every blow. And then it happened. The mother came running down the hall, stopped in the doorway, and yelled, "Stop! NO More! I'm his mother." We all looked up- all hands off the patient. At this point the attending physician was also in the doorway and he and the fellow clarified with the mother what stopping CPR would mean and verified that this indeed was her wish. With tears streaming down her face, she sobbed, "Yes. Yes." And with that we turned off the pumps and stepped back. I stood there holding the mother as we watched the agonal heart rhythm on the monitor...28, 23, 10, asystole. We checked- no pulse. And he was gone.
The monitor no sooner read asystole and the sister came running back in. She threw herself over her brother and let out a blood curdling scream. The crowds started to dissipate from the room and the fellow, J, and I began to comfort the family. After turning off the monitors and stocking the room with tissues, we all left and let the family grieve. I called the priest. It broke my heart as I watched the father pace frantically outside the room, refusing to set foot inside. After the priest left, I heard a noise coming from the room. I looked up from my paperwork and started walking towards the room...
Oh Dios de quién Único Hijo nos ha otorgado los beneficios de la vida eterna, concédenos la gracia que te pedimos mientras meditamos los Misterios del Mas Santo Rosario de la Bienaventurada Virgen María, debemos imitar lo que contienen y obtener lo que prometen, a través del mismo Cristo Nuestro Señor. Amen.
Over the last two weeks I'd listened to X's family chant prayers at his bedside, but suddenly I was moved. Not overly religious, but still connected to my Catholic roots, I stopped to think about what they were saying.
Let us pray. O God, whose only begotten Son, by His life, death, and resurrection, has purchased for us the rewards of eternal life, grant, we beseech Thee, that meditating upon these mysteries of the Most Holy Rosary of the Blessed Virgin Mary, we may imitate what they contain and obtain what they promise, through the same Christ Our Lord. Amen.
Jesus died at 33, their son didn't even make it to 30.
The post mortem care that followed was grueling. It took over 3 hours. Removing the dressings churned my stomach. X's skin was green with infection and textured with fungus. When all was said and done, I called the family in one last time to say good bye. As they kissed him their final goodbyes, I stopped the mother in the doorway and took her hand. I opened her clenched fist and placed something in it. She brought her hand closer to her face and opened her fingers--an ID band. She threw her hands up around my neck and sobbed, "Thank You. Thank You." I may not have been able to save her son, but I sure hope I can preserve his memory.
X was accepted as in international transfer five weeks post burn. Although I've seen many patients with his % burn survive, the fact that at five weeks out none of his wounds were closed was not favorable. When X finally arrived in New York at the beginning of December, he was in renal failure, maxed on dopamine and norepinepherine for his blood pressure, thrombocytopenic, in respiratory failure and ventilator dependent, and in septic shock. Additionally a MRI of his brain revealed an acute cerebellar infarct. He had six surgeries for debridment and skin grafting but none of them took as his body was invaded with fungus and bacteria. I took care of him the better half of the last two weeks and grew to know his family well. They halted their lives abroad and moved here to keep vigil at his side. They waited and prayed and waited and prayed and waited and waited and waited and prayed.
In the last two weeks, X grew sicker and sicker. He had showed some signs of improvement early on (return of some kidney function with oliguric output, improved ABG's, improved coagulation, fewer bacteria invading his wounds) but he took a turn for the worst...
Pseudomonas in the sputum, blood, and urine.
Acetinobacter in the sputum.
Candida on the skin and in the blood.
Thrombocytopenia
ARDS
Pulmonary Edema
Acute Renal Failure
Collapsed Lung
Sepsis
Acidosis
20 kilos of fluid overload with edema making him unrecognizable
In those 25 hours of work I administered 8 units of blood, 8 units of FFP, 10 units of platelets but he remained thrombocytopenic.
The ventilator was on 100%FiO2 and he was still lethally acidotic.
He required continuous deep lavage suctioning that involved removing him from the ventilator and breaking PEEP causing his blood pressure to plummet.
He was so unstable we couldn't turn him to put him on dry sheets, yet he was putting out 11 liters a day in bed drainage (yes, we suction and measure this).
He was two days overdue for day #5 post-operative dressing (POD) change.
His eyes were dilated and minimally responsive.
He was maxed out on Dopamine, Levophed, Neosenepherine, and Epinephrine.
I arrived at work on Monday and was partially surprised to find X still alive. The three hours prior to my arrival his blood pressure was resting around 68/40, his heart rate tachycardic in the 110's, and his O2 sat around 73%. The attending physicians held a discussion with the family during the day and I thought they were leading in favor of DNR, but in a desperate twist of fate the father disagreed and said he wanted "every thing possible" to be done.
During the day, the family had kept vigil at the bedside, never more than three visitors at a time. In the middle of report from the day nurse, Xs alarms sounded, his O2 sat was 65%, he needed to suctioned. The day nurse (J) and I went in and prepared to suction. We no sooner finished when his heart rate began to plummet: 110-90-80-75-70-60-55......
J yelled to get some atropine began bagging the patient. I hopped up to begin compressions. In rolled the code cart and so began the code. His venous access lines ( a right internal jugular TLC, a left femoral TLC, and left femoral Aline) were a mass of "spaghetti" coming from the 13 pumps running on either side of his bed; however, when the atropine arrived J started pushing meds, I continued compressions ,and the fellow took over bagging. I felt ribs snap, I saw my artificial compression "V-tach" heart rate on the monitor, my triceps and deltoids tightening with every blow. And then it happened. The mother came running down the hall, stopped in the doorway, and yelled, "Stop! NO More! I'm his mother." We all looked up- all hands off the patient. At this point the attending physician was also in the doorway and he and the fellow clarified with the mother what stopping CPR would mean and verified that this indeed was her wish. With tears streaming down her face, she sobbed, "Yes. Yes." And with that we turned off the pumps and stepped back. I stood there holding the mother as we watched the agonal heart rhythm on the monitor...28, 23, 10, asystole. We checked- no pulse. And he was gone.
The monitor no sooner read asystole and the sister came running back in. She threw herself over her brother and let out a blood curdling scream. The crowds started to dissipate from the room and the fellow, J, and I began to comfort the family. After turning off the monitors and stocking the room with tissues, we all left and let the family grieve. I called the priest. It broke my heart as I watched the father pace frantically outside the room, refusing to set foot inside. After the priest left, I heard a noise coming from the room. I looked up from my paperwork and started walking towards the room...
Oh Dios de quién Único Hijo nos ha otorgado los beneficios de la vida eterna, concédenos la gracia que te pedimos mientras meditamos los Misterios del Mas Santo Rosario de la Bienaventurada Virgen María, debemos imitar lo que contienen y obtener lo que prometen, a través del mismo Cristo Nuestro Señor. Amen.
Over the last two weeks I'd listened to X's family chant prayers at his bedside, but suddenly I was moved. Not overly religious, but still connected to my Catholic roots, I stopped to think about what they were saying.
Let us pray. O God, whose only begotten Son, by His life, death, and resurrection, has purchased for us the rewards of eternal life, grant, we beseech Thee, that meditating upon these mysteries of the Most Holy Rosary of the Blessed Virgin Mary, we may imitate what they contain and obtain what they promise, through the same Christ Our Lord. Amen.
Jesus died at 33, their son didn't even make it to 30.
The post mortem care that followed was grueling. It took over 3 hours. Removing the dressings churned my stomach. X's skin was green with infection and textured with fungus. When all was said and done, I called the family in one last time to say good bye. As they kissed him their final goodbyes, I stopped the mother in the doorway and took her hand. I opened her clenched fist and placed something in it. She brought her hand closer to her face and opened her fingers--an ID band. She threw her hands up around my neck and sobbed, "Thank You. Thank You." I may not have been able to save her son, but I sure hope I can preserve his memory.
Sunday, December 14, 2008
Exhausted
Holy Moly, I’ve been MIA and I have lots of catch you all up on. First, the entire month of November I was feeling really down. Some days it took all the energy I had just to get out of bed. I wasn’t excited about anything, nor did I want to do anything. I even hated going to the gym or running (yes, you read that correctly). I was rather concerned. I knew it wasn’t normal to feel that way; however, I didn’t care much about anything.
When my family saw me at Thanksgiving, they thought I looked bad. My schedule wasn’t helping my case. I was working 5 nights a week, 12+ hours a night, and not sleeping more than 3 or 4 hours in between shifts. I don’t care what you say, sleeping during the day does not even compare to sleeping at night. Plus, all this exhaustion was wreaking havoc on my body.
I’m very conscientious about what I eat, how my clothes fit, my weight etc. So when my pants started getting tighter ,and I knew I hadn’t changed my eating habits or how much I exercised, my stress only increased. I finally reached my breaking point when N called, asking me to dinner, and I broke down and cried. I told her that I’m just miserable. I hate working nights. It’s lonely. It’s isolating. I can go an entire week without seeing my roommate. I don’t do that much for myself and the few things that I do (i.e. working out, running, cooking) I no longer enjoy. After an hour of her listening to me sob and sob and sob, she convinced me to go out for sushi in the Village. It was freezing cold outside, but I needed the fresh air. After another restless night’s sleep (that’s the other problem, now that I’m used to staying up at night, I can’t sleep on my days off) I called my doctor. Not being one who EVER takes medication, I now have lovely prescription for some @mbien. Magic.Little.Pill.
Even better than the fake sleep that I’ve been getting is the fact that I’m doing a month long rotation on days. It’s heaven. They’ve also been giving me a lot more responsibility at work. In addition to acting as charge nurse, I’m also precepting some of our new nurses. It’s extremely flattering to be given so much responsibility after only working in the BICU for 16 months.
My transition from nights to days was a little hairy. I worked Thursday and Friday nights, had Saturday off, then worked Sunday, Monday, Tuesday days. Despite the fact that I hadn’t worked a day shift in a year, I was in charge on Sunday, Monday, and Tuesday. Let the games begin!
I won’t bore you with the details but we were slammed with boarder patients from the PACU, two of which were extremely unstable and ended up getting emergently intubated and rushed back to the OR. One patient died. One patient coded six times over 48 hours. The repeat coder also ended up swanned (twice, after the first one was defective), had a transvenous pacer placed by cardiology, then had a GI bleed, then stopped oxygenating his body as indicated by his PO2 of 45 from his ABG.
On top of all this activity, we had another patient who came in intubated with an unknown medical history; she was found down in a house fire after smoking and drinking in bed. Turns out this lady had quite a history with IV drug use and alcohol abuse, so she was damn near impossible to sedate due to her high tolerance of narcotics. Her magic cocktail turned out to be 150mcg of Fentanyl and 50mcg of Propofol.
The above situations kept all of us doctors and nurses very busy, but I had a very emotional experience on Monday. I can’t remember if I ever posted about this patient, but back in July I admitted a five year-old boy started a house fire and ended up with 65% total body surface area full thickness burns. He was intaubted and sedated, teetering the line between life and death.
The night I admitted him, I thought-on more than one occasion- that we were going to loose him. His mother was the first parent I had to address regarding life and death. I took off all my surgical garb, took her by the hand, and walked her into her son’s hospital room. I explained, in lay man’s terms, the physiology of burns. My knees knocked, but my voice never faltered, as I told her that the first 72 hours were the most critical. I caught her in my arms as she broke down; she wept on my shoulder like baby.
I took care of this boy four nights in a row and countless times over the next few months. His hospital stay was complicated by infections, sloughed graphs, respiratory and neurological issues, but every time I took care of him I felt a sense of pride and hope. I was there the afternoon they extuabted him; I watched him take his first non- ventilator assisted breath; I teared up.
This little guy became a fixture on our unit. Everyone knew him, and he knew everyone. Two weeks ago he celebrated his 6th birthday, it was a 24-hour, non-stop party. Everyone from the attending physicians to the house keeping staff joined in the celebration. I knew he was getting better, but the idea of him leaving never crossed my mind. So when I found out that he would be discharged to rehab on Monday, my stomach knotted.
Monday morning I went into his room and had a long talk with him. I told him that although I was very sad to see him go, it was a very special day for us both. For him it marked astounding progress, for me it was a happy ending to a six month journey. I can’t begin to express how meaningful it was for me to discharge the very patient who I thought I would loose.
As I reviewed the mounds of paperwork with his mother, she looked up at me and started to cry. Much like the first night I met her, I caught her in my arms and she wept on my shoulder. However, this time her tears were that of joy not fear. She looked at me, as I wiped away her tears, and mouthed “thank you.” And it was that moment that reminded me why I do what I do. It makes the long hours, the back-breaking work, the stress, and the frustration all worth it. I must have some angels up in heaven, because this reminder couldn’t have come at a better time. Once again, I feel at peace, ready to take on whatever comes my way.
When my family saw me at Thanksgiving, they thought I looked bad. My schedule wasn’t helping my case. I was working 5 nights a week, 12+ hours a night, and not sleeping more than 3 or 4 hours in between shifts. I don’t care what you say, sleeping during the day does not even compare to sleeping at night. Plus, all this exhaustion was wreaking havoc on my body.
I’m very conscientious about what I eat, how my clothes fit, my weight etc. So when my pants started getting tighter ,and I knew I hadn’t changed my eating habits or how much I exercised, my stress only increased. I finally reached my breaking point when N called, asking me to dinner, and I broke down and cried. I told her that I’m just miserable. I hate working nights. It’s lonely. It’s isolating. I can go an entire week without seeing my roommate. I don’t do that much for myself and the few things that I do (i.e. working out, running, cooking) I no longer enjoy. After an hour of her listening to me sob and sob and sob, she convinced me to go out for sushi in the Village. It was freezing cold outside, but I needed the fresh air. After another restless night’s sleep (that’s the other problem, now that I’m used to staying up at night, I can’t sleep on my days off) I called my doctor. Not being one who EVER takes medication, I now have lovely prescription for some @mbien. Magic.Little.Pill.
Even better than the fake sleep that I’ve been getting is the fact that I’m doing a month long rotation on days. It’s heaven. They’ve also been giving me a lot more responsibility at work. In addition to acting as charge nurse, I’m also precepting some of our new nurses. It’s extremely flattering to be given so much responsibility after only working in the BICU for 16 months.
My transition from nights to days was a little hairy. I worked Thursday and Friday nights, had Saturday off, then worked Sunday, Monday, Tuesday days. Despite the fact that I hadn’t worked a day shift in a year, I was in charge on Sunday, Monday, and Tuesday. Let the games begin!
I won’t bore you with the details but we were slammed with boarder patients from the PACU, two of which were extremely unstable and ended up getting emergently intubated and rushed back to the OR. One patient died. One patient coded six times over 48 hours. The repeat coder also ended up swanned (twice, after the first one was defective), had a transvenous pacer placed by cardiology, then had a GI bleed, then stopped oxygenating his body as indicated by his PO2 of 45 from his ABG.
On top of all this activity, we had another patient who came in intubated with an unknown medical history; she was found down in a house fire after smoking and drinking in bed. Turns out this lady had quite a history with IV drug use and alcohol abuse, so she was damn near impossible to sedate due to her high tolerance of narcotics. Her magic cocktail turned out to be 150mcg of Fentanyl and 50mcg of Propofol.
The above situations kept all of us doctors and nurses very busy, but I had a very emotional experience on Monday. I can’t remember if I ever posted about this patient, but back in July I admitted a five year-old boy started a house fire and ended up with 65% total body surface area full thickness burns. He was intaubted and sedated, teetering the line between life and death.
The night I admitted him, I thought-on more than one occasion- that we were going to loose him. His mother was the first parent I had to address regarding life and death. I took off all my surgical garb, took her by the hand, and walked her into her son’s hospital room. I explained, in lay man’s terms, the physiology of burns. My knees knocked, but my voice never faltered, as I told her that the first 72 hours were the most critical. I caught her in my arms as she broke down; she wept on my shoulder like baby.
I took care of this boy four nights in a row and countless times over the next few months. His hospital stay was complicated by infections, sloughed graphs, respiratory and neurological issues, but every time I took care of him I felt a sense of pride and hope. I was there the afternoon they extuabted him; I watched him take his first non- ventilator assisted breath; I teared up.
This little guy became a fixture on our unit. Everyone knew him, and he knew everyone. Two weeks ago he celebrated his 6th birthday, it was a 24-hour, non-stop party. Everyone from the attending physicians to the house keeping staff joined in the celebration. I knew he was getting better, but the idea of him leaving never crossed my mind. So when I found out that he would be discharged to rehab on Monday, my stomach knotted.
Monday morning I went into his room and had a long talk with him. I told him that although I was very sad to see him go, it was a very special day for us both. For him it marked astounding progress, for me it was a happy ending to a six month journey. I can’t begin to express how meaningful it was for me to discharge the very patient who I thought I would loose.
As I reviewed the mounds of paperwork with his mother, she looked up at me and started to cry. Much like the first night I met her, I caught her in my arms and she wept on my shoulder. However, this time her tears were that of joy not fear. She looked at me, as I wiped away her tears, and mouthed “thank you.” And it was that moment that reminded me why I do what I do. It makes the long hours, the back-breaking work, the stress, and the frustration all worth it. I must have some angels up in heaven, because this reminder couldn’t have come at a better time. Once again, I feel at peace, ready to take on whatever comes my way.
Monday, November 10, 2008
leaps and bounds
Call me crazy, but when I walked into my patient's room and saw all this, I got excited.....
Salem Sump to wall suction- bilious drainage
Jejunostomy tube- acting as feeding tube with Osmolyte @ 60cc/hr
Trachestomy- #6 shiley, cuffed
Right femoral arterial line
Right femoral triple lumen catheter- Brown: CVP; Blue: Insulin, TPN, & Lipids; White: Ativan, Fentanyl, Dopamine,& Levophed
Left femoral triple lumen catheter- Brown: Sodium Bicaronate; Blue: Polymixin/Tobramycin/Linezolid; White-heparin drip
Foley Catheter-transducing bladder pressures
Rectal tube-(ah, do you need a description?)
Wound Vac to Abdomen
Wound Vac to right and left foot
3 canisters to wall suction- weeping wound bed drainage
There was a point in time, not too long ago, where patients like this made me shudder with fear. However, at some point in the last 16 months, I became a nurse- a real nurse. One who's excited at the challange of caring for the sickest patients, helping them along the fine line between life and death. Yes my loyal reader
Friday, September 05, 2008
Love 'Em, Don't Leave 'Em
I took report on my patient tonight and my heart sank.
80% burns, self inflicted.
He didn't feel loved, so instead he doused himself in lighter fluid and struck a match. If I have learned anything in the last 13 months, it's that suicide by fire is a long, painful, and not usually successful (initially). Instead, the patient waits until their body sucomes sepsis.
He's got a machine breathing for him.
His blood pressure is dependant on high doses of medication.
He requires continuous sedation of fentanyl and ativan.
His skin has been excised and cadaver skin is temporarily grafted onto his body.
Why did he do it? He's not awake to tell us. But we did learn from his friend that he recently came out of the closet...it wasn't well received. His family couldn't accept his way of life. He had failed- in their minds, to be the masculine ideal people hold on a pedestal. His family turned their back on him and now they risk loosing him. They couldn't see their son for all that he was. They were blinded by the gender issue.
I watched them sit at his bedside today, tears flowing. I heard them say, "I just don't get why he'd do this to us." I had to try hard to bite my tongue. They truly believed that their son did this to spite them, never considering that maybe it was his cry for help and longing for love.
And now I ask you all to do this. Love your kids for who they are, no what you think they should be. Let them live. Let the little girls play with cars and roll around in the dirt. Let the little boys play with the kitchen sets and put on dress up clothes. Cherish the time you have with them.
80% burns, self inflicted.
He didn't feel loved, so instead he doused himself in lighter fluid and struck a match. If I have learned anything in the last 13 months, it's that suicide by fire is a long, painful, and not usually successful (initially). Instead, the patient waits until their body sucomes sepsis.
He's got a machine breathing for him.
His blood pressure is dependant on high doses of medication.
He requires continuous sedation of fentanyl and ativan.
His skin has been excised and cadaver skin is temporarily grafted onto his body.
Why did he do it? He's not awake to tell us. But we did learn from his friend that he recently came out of the closet...it wasn't well received. His family couldn't accept his way of life. He had failed- in their minds, to be the masculine ideal people hold on a pedestal. His family turned their back on him and now they risk loosing him. They couldn't see their son for all that he was. They were blinded by the gender issue.
I watched them sit at his bedside today, tears flowing. I heard them say, "I just don't get why he'd do this to us." I had to try hard to bite my tongue. They truly believed that their son did this to spite them, never considering that maybe it was his cry for help and longing for love.
And now I ask you all to do this. Love your kids for who they are, no what you think they should be. Let them live. Let the little girls play with cars and roll around in the dirt. Let the little boys play with the kitchen sets and put on dress up clothes. Cherish the time you have with them.
Sunday, August 24, 2008
with grace
my arms hurt.
my back hurts.
my neck is cricked.
I had a long night.
no! Get your mind out of the gutter.
we coded a patient (for an hour) twice.
i may be small, but i'm certainly mighty.
i broke ribs.
maxed out on levo, dopa, dobutamine,and epi, we never got her back from asystole.
she didn't make it.
RIP
my back hurts.
my neck is cricked.
I had a long night.
no! Get your mind out of the gutter.
we coded a patient (for an hour) twice.
i may be small, but i'm certainly mighty.
i broke ribs.
maxed out on levo, dopa, dobutamine,and epi, we never got her back from asystole.
she didn't make it.
RIP
Sunday, August 17, 2008
I Should Get Paid for This
Even before I knew ANYTHING about being a nurse (i.e. NSO during freshman orientation) I got asked silly nurse questions. Not going to lie, I had no clue when I answered these questions...
"Am I going to die from drinking this Jungle Juice?"
IF you die, so will the thousand other people drinking from this barrel. Fill 'er up
"Can I drink and take Tylenol/antibiotics/birth control"
I'd skip the Tylenol, but if you are going to drink and want to avoid an "accident" I'd go with the birth control
"Will I get herpes from sitting on the toilet in the dorms?".
No greater chance of getting it from the toilet seat than from that sketchy frat boy you hooked up with last night.
As the years passed, I grew more knowledgeable and was able to actually give some helpful advice. I have no problem when my friends come to me with "health questions", I always just hope I have an answer. I guess in a way it makes them feel better, even if I just tell them what they already know (i.e. "I'd say you need to go to the ER for an x-ray, the bone IS sticking out.")
Last week, Craig approached me with a nurse question. He pulled up his pant leg and said, "Do you think these are infected?" I swallowed hard as I looked at the welts on his legs, covered in green scabs with blanching red rings around them. Did I mention the edema in his leg and ankle.
(original image from wikipedia)
ME: "Craig! You are on your way to nasty case of cellulits. You need to go the doctor and get some antibiotics. We admit patients for cellulitis, you don't want it to go systemic."
Craig: "You mean I can't just take some Tylenol and put on some cream?"
ME: "Uh, has it worked yet?"
Craig: "No. Oh I guess you're right. I'll go to the doctor. Wait, I don't have a doctor here. Am I going to die?"
ME: "No, you just need to See a doctor. So go to the ER"
Craig: "But isn't that going to be a long wait?"
ME: "Well it's going to be a lot longer if you don't get it treated and have to get admitted to the hospital for a course of IV antibiotics."
Craig: "Okay, thanks nurse Kelly.I'll go"
ME: "Call me if you need anything. I'll check in with you later."
4 hours later
Craig: "Nurse Kelly. You were right. They checked me all out and gave me some antibiotics. Thanks."
ME: "No problem Craig. Feel better. See you tomorrow."
36 hours later, 8am
MY cell phone goes off, it rings again, and again. I hop out of bed, thinking something is truly wrong. It's Craig. I call him back.
"Hi Nurse Kelly. Did I wake you?"
ME: "Uhhm, well I guess I had to get up anyways."
Craig:"Good. Well, okay, so yeah like I started the antibiotics and my legs are looking better but now I have this hard lump under my belly button and it's red and kinda sore."
ME: "Is it itchy?"
Craig: "No, just hurts and looks gross. Do I have skin cancer?"
ME: "Take some benadryl, and Tylenol, and put a cool compress on it. If it's not better in the morning or is getting worse, go to the doctor."
Craig: "But Nurse Kelly, I don't have a doctor."
ME: "Well then, I guess you'll have to go to the ER (again). Have you thought about getting a doctor in the area? What is your insurance, I'll look into it for you."
Craig: "Do you think I can get in and out quick because I was just seen there? Like a preferred patient?"
ME: "Craig, we aren't talking about some luxury hotel chain, we are talking about a hospital. You (and your belly button ailments) will have to wait like everyone else. haha"
Craig: "Okay, guess you are right. I'll call you later."
ME: "Sounds good. Feel better and keep me updated."
I managed to dose back off for an hour or two, but it wasn't quite the restful sleep I was longing for. I kept dreaming about Craig's weird belly button issue. Just another day in the life of Nurse Kelly.
"Am I going to die from drinking this Jungle Juice?"
IF you die, so will the thousand other people drinking from this barrel. Fill 'er up
"Can I drink and take Tylenol/antibiotics/birth control"
I'd skip the Tylenol, but if you are going to drink and want to avoid an "accident" I'd go with the birth control
"Will I get herpes from sitting on the toilet in the dorms?".
No greater chance of getting it from the toilet seat than from that sketchy frat boy you hooked up with last night.
As the years passed, I grew more knowledgeable and was able to actually give some helpful advice. I have no problem when my friends come to me with "health questions", I always just hope I have an answer. I guess in a way it makes them feel better, even if I just tell them what they already know (i.e. "I'd say you need to go to the ER for an x-ray, the bone IS sticking out.")
Last week, Craig approached me with a nurse question. He pulled up his pant leg and said, "Do you think these are infected?" I swallowed hard as I looked at the welts on his legs, covered in green scabs with blanching red rings around them. Did I mention the edema in his leg and ankle.
(original image from wikipedia)ME: "Craig! You are on your way to nasty case of cellulits. You need to go the doctor and get some antibiotics. We admit patients for cellulitis, you don't want it to go systemic."
Craig: "You mean I can't just take some Tylenol and put on some cream?"
ME: "Uh, has it worked yet?"
Craig: "No. Oh I guess you're right. I'll go to the doctor. Wait, I don't have a doctor here. Am I going to die?"
ME: "No, you just need to See a doctor. So go to the ER"
Craig: "But isn't that going to be a long wait?"
ME: "Well it's going to be a lot longer if you don't get it treated and have to get admitted to the hospital for a course of IV antibiotics."
Craig: "Okay, thanks nurse Kelly.I'll go"
ME: "Call me if you need anything. I'll check in with you later."
4 hours later
Craig: "Nurse Kelly. You were right. They checked me all out and gave me some antibiotics. Thanks."
ME: "No problem Craig. Feel better. See you tomorrow."
36 hours later, 8am
MY cell phone goes off, it rings again, and again. I hop out of bed, thinking something is truly wrong. It's Craig. I call him back.
"Hi Nurse Kelly. Did I wake you?"
ME: "Uhhm, well I guess I had to get up anyways."
Craig:"Good. Well, okay, so yeah like I started the antibiotics and my legs are looking better but now I have this hard lump under my belly button and it's red and kinda sore."
ME: "Is it itchy?"
Craig: "No, just hurts and looks gross. Do I have skin cancer?"
ME: "Take some benadryl, and Tylenol, and put a cool compress on it. If it's not better in the morning or is getting worse, go to the doctor."
Craig: "But Nurse Kelly, I don't have a doctor."
ME: "Well then, I guess you'll have to go to the ER (again). Have you thought about getting a doctor in the area? What is your insurance, I'll look into it for you."
Craig: "Do you think I can get in and out quick because I was just seen there? Like a preferred patient?"
ME: "Craig, we aren't talking about some luxury hotel chain, we are talking about a hospital. You (and your belly button ailments) will have to wait like everyone else. haha"
Craig: "Okay, guess you are right. I'll call you later."
ME: "Sounds good. Feel better and keep me updated."
I managed to dose back off for an hour or two, but it wasn't quite the restful sleep I was longing for. I kept dreaming about Craig's weird belly button issue. Just another day in the life of Nurse Kelly.
Sunday, August 10, 2008
what happens when you get septic
this is night #5 of a 7 consecutive shift stint with the sickest patient i've ever taken care of (I think).
some highlights of the clinical situation thus far:
*maxed out on dopamine, added levophed drip
*H/H =7.0 / 21.2...2 units PRBC transfused
*gram negative sepsis as seen in the blood stream and BAL...Aztreozam Abx therapy
*pre-renal failure (>10cc/hr for 15 hours) despite fluids going at 1000cc/hr
*patient CXR showing patchy infiltrates and fluid: patient not oxygenating or ventilating well
*SWAN Ganz inserted. Cardiac output > 13, Wedge high 20's, CVP 28-34.
*septic shock
*started on Xigris
*PTT > 150...xigris stopped...4 units FFP transfused
*ABG: 7.22/55/67/18...FiO2 on 100%...8 sets of ventialtor changes made
*8 liters of bed drainage per shift
*1 liter of diarrhea in 3 hours, C.Diff samples sent~positive growth...rectal tube inserted
stay tuned. 2 more nights to go.
some highlights of the clinical situation thus far:
*maxed out on dopamine, added levophed drip
*H/H =7.0 / 21.2...2 units PRBC transfused
*gram negative sepsis as seen in the blood stream and BAL...Aztreozam Abx therapy
*pre-renal failure (>10cc/hr for 15 hours) despite fluids going at 1000cc/hr
*patient CXR showing patchy infiltrates and fluid: patient not oxygenating or ventilating well
*SWAN Ganz inserted. Cardiac output > 13, Wedge high 20's, CVP 28-34.
*septic shock
*started on Xigris
*PTT > 150...xigris stopped...4 units FFP transfused
*ABG: 7.22/55/67/18...FiO2 on 100%...8 sets of ventialtor changes made
*8 liters of bed drainage per shift
*1 liter of diarrhea in 3 hours, C.Diff samples sent~positive growth...rectal tube inserted
stay tuned. 2 more nights to go.
Friday, August 01, 2008
dominos
Last night was my first night back at work, actually taking care of patients, after almost 3 weeks of time off to heal my little injury (which is getting better every day, thankyouverymuch).
My boss had called earlier in the day, as in 8am (like that the heck would I be doing at that time of day? Sleep?!?! Apparently not). He called tomake sure that I was coming in because staffing is atrocious "see how I was feeling". I assured him that I'd be in and would see how I felt. I did make one request. I told him that I would prefer one very sick, preferable vented patient, over a few "walkie talkie" step-down patients. Have I ever mentioned that I loathe the call bell and think it was possibly invented for the sole reason of tormenting overworked staff??
I arrived at work early (after a year I still overestimate the amount of time it will take me to walk 5 blocks) and am surprised to find that my assignment is actually a "sickie". Oh wait, he's sick, but he's also a bariatric patient (a mere 206 kilos). Um yeah, so like how am I going to maneuver this man? With help, of course. My coworkers were great with lending a hand (or two, or three, or four) but my adventures didn't end with his size. All those with weak stomachs and/or those who want to eat in the next hour, don't read on. During the course of the night he started to blow snot bubbles-one popped in my face (amen to face shields). He projective vomited (did I mention he also has a tracheostomy), that was delicious. Despite giving pharmacy a 2 hour heads up that I needed a new ativan drip, they were 45 minutes late in supplying me a new one. You know how it goes from here...Patient sedation lessons, patient pulls out NG tube that the attending had placed. While I was replacing the NGT tube, the patients A-line pressure bag malfunctioned and I lost the waveform. After 2 attempts the NGT goes in but the patient just coughed off his trach cap and goo flies everywhere. I attempt to prop him on his side and what to do you know? Oh yes, some of the worst smelling farts ever. Only good thing is that there was none of that brown delight, to accompany the odor. That's when my foot skid on the floor. Oh yes, I had just stepped into a the pile of puke that I missed when cleaning up the vomit with cl0r0x wipes (remind me again why we pay a housekeeping staff?) I squatted down to examine the problem. WHOOPS, OUCH, F@c^! That didn't feel good. Now, stuck in a squat, I just started to laugh and laugh and laugh. What else could I do? I pulled myself up and just started to fix all my messes.
I'm back tonight for #2 of 4. Stay tuned, it's always an adventure when nurse Kelly is around.
My boss had called earlier in the day, as in 8am (like that the heck would I be doing at that time of day? Sleep?!?! Apparently not). He called to
I arrived at work early (after a year I still overestimate the amount of time it will take me to walk 5 blocks) and am surprised to find that my assignment is actually a "sickie". Oh wait, he's sick, but he's also a bariatric patient (a mere 206 kilos). Um yeah, so like how am I going to maneuver this man? With help, of course. My coworkers were great with lending a hand (or two, or three, or four) but my adventures didn't end with his size. All those with weak stomachs and/or those who want to eat in the next hour, don't read on. During the course of the night he started to blow snot bubbles-one popped in my face (amen to face shields). He projective vomited (did I mention he also has a tracheostomy), that was delicious. Despite giving pharmacy a 2 hour heads up that I needed a new ativan drip, they were 45 minutes late in supplying me a new one. You know how it goes from here...Patient sedation lessons, patient pulls out NG tube that the attending had placed. While I was replacing the NGT tube, the patients A-line pressure bag malfunctioned and I lost the waveform. After 2 attempts the NGT goes in but the patient just coughed off his trach cap and goo flies everywhere. I attempt to prop him on his side and what to do you know? Oh yes, some of the worst smelling farts ever. Only good thing is that there was none of that brown delight, to accompany the odor. That's when my foot skid on the floor. Oh yes, I had just stepped into a the pile of puke that I missed when cleaning up the vomit with cl0r0x wipes (remind me again why we pay a housekeeping staff?) I squatted down to examine the problem. WHOOPS, OUCH, F@c^! That didn't feel good. Now, stuck in a squat, I just started to laugh and laugh and laugh. What else could I do? I pulled myself up and just started to fix all my messes.
Clean puke: check
Get new pressure bag for A-line: check
Reinsert feeding tube: check
Suction out patients mouth and nose and tube for any residual vomit: check, check, check
Completely change patients linens and bed (2nd time in less than 2 hours): check
Wash patients face: check
Take off gloves; Rremove mask; Wash hands; Sit in chair; Pray that 8am isn't really still 5 hours away
I'm back tonight for #2 of 4. Stay tuned, it's always an adventure when nurse Kelly is around.
Saturday, May 03, 2008
A Letter to My Nemice
Dear On-Call Resident from Sunday Night,
Normally, I ignore your larger than life attitude and pompous arrogance. However, after Sunday night, you really should rethink how you treat the nurses. We're human too.
When I paged you the first time and you didn't call back, I gave you the benefit of the doubt. This a very busy ICU and we have lots of sick patients. When I paged you the second time and you didn't call back, I gave you the benefit of the doubt, I knew there was an admission in the ER. When I paged you the third time via text page to relay my message that Ms. L's complaints of pain at her IJ removal site, that she couldn't move her neck, and it was painful to the touch and you STILL didn't call me back...I started to get annoyed. Sorry sister, I went over your head and paged the fellow. Lucky for you, she was tagging along on your little adventures and didn't get right back to me.
I really do not appreciate the fact that when I finally saw you on the floor, 45 minutes after the 3rd page, and approached you about seeing my patient that you barked at me, "I'll get to it." Have you not paid any attention to SBAR. A time frame would have been nice. Lucky for you, I bit my tongue and repeated, "This patient needs to be seen now. I've been paging you for almost 3 hours. She is in excrutiang pain and it's affecting her vital signs. She's tachycardic and hypertensive and diaphoretic. Thankyouverymuch."
Your throwing of the pen across the counter and slamming of the papers was quite unnecessary. Your curt tone and rough "assessment" of my patient was uncalled for. When she flinched before you even touched her neck, you should have backed off, not dove right in to make the woman scream. Your thought that, "She's got some phlebitis. Nothing I can do for it tonight, she's already anti-coagualted." Wasn't that helpfull. As you went about your business, I kept an eye on you. I know that when I paged you again two hours later to report the patient was having some minor mental status changes, that you were sitting at the computer. You should have come to see the patient when you got up before you decided to go bronch Mr. S. In case you were wondering, I most certainly did page you three times while you were in with Mr. S. I will not be ignored!
When the patients lab values came back at 4am (did I mention that this patient was an extremely hard stick but that I was able to get blood myself, without paging you to do an arterial stick?!?!?) and her WBC count had jumped from 11.5 to 17.5 and I relayed this message onto you and you replied, "Yeah. So. It's 4am I haven't looked at lab values yet." THAT WASN'T COOL. Given this patients current condition and her history, you should have been in that room faster than lighting. I'm really happy that when you finally went in to assess the patient, after I followed you around like a lost puppy dog for 15 minutes, and you then touched the site and Goren puss came oozing out that I was standing right there to comment, "Phelebitis, hunh?" Boy did that comment feel good! Sorry it was inconvenient for you that you now had to culture the patient but maybe you should have thought about that hours ago when I first brought this to your attention.
I had to bite my tongue hard when you bitched and moaned about now having "another thing to do." Correct me if I'm wrong, isn't this your job? Oh yeah, that's right, my error. Someone made you take the MCAT's, apply to medical school, complete 4 years of medical school, apply to a residency program, and become a doctor. Seriously lady, get a grip.
after a quick prayer to the IV God's I managed to get an IV in this ladies arm so she could get her STAT dose of antibiotics. Did I gloat to you? NO.
I found it ironic that during AM rounds with the fellow you provided a beautiful narrative of the nights events...perfectly describing what YOU did, what YOU noticed, what YOU caught...weren't you the one who didn't even want to assess the patient?
So can you explain to me why you did nothing but complain about "the nurses" all night. Oh and FYI, I heard when you said, "The one with glasses (me)... She's ridiculously demanding and just doesn't get it. She couldn't. She's just a nurse". But I DO GET IT! I think you don't. Yes, I am a nurse and I'm not disputing that fact. However, I think you need to realize something. I'm not some dumb ass who says stuff to hear myself speak. Look lady, I've got an Ivy League education, perhaps better than your no-name medical school education, and I've had enough of your BS.
Do me a favor, actually two of them. First, shut up! Then, grow up! We're all here for the good of the patients, but if that's too much for you, I've got some bad news...you just wasted $250,000 on an education that isn't going to lead to a career.
Signed,
Nurse Kelly
(better thought of by you as "the relentless dumbass who clearly identified what was wrong with the patient hours before you even looked at the patient but isn't capable of making recommendations because she's just a nurse")
Normally, I ignore your larger than life attitude and pompous arrogance. However, after Sunday night, you really should rethink how you treat the nurses. We're human too.
When I paged you the first time and you didn't call back, I gave you the benefit of the doubt. This a very busy ICU and we have lots of sick patients. When I paged you the second time and you didn't call back, I gave you the benefit of the doubt, I knew there was an admission in the ER. When I paged you the third time via text page to relay my message that Ms. L's complaints of pain at her IJ removal site, that she couldn't move her neck, and it was painful to the touch and you STILL didn't call me back...I started to get annoyed. Sorry sister, I went over your head and paged the fellow. Lucky for you, she was tagging along on your little adventures and didn't get right back to me.
I really do not appreciate the fact that when I finally saw you on the floor, 45 minutes after the 3rd page, and approached you about seeing my patient that you barked at me, "I'll get to it." Have you not paid any attention to SBAR. A time frame would have been nice. Lucky for you, I bit my tongue and repeated, "This patient needs to be seen now. I've been paging you for almost 3 hours. She is in excrutiang pain and it's affecting her vital signs. She's tachycardic and hypertensive and diaphoretic. Thankyouverymuch."
Your throwing of the pen across the counter and slamming of the papers was quite unnecessary. Your curt tone and rough "assessment" of my patient was uncalled for. When she flinched before you even touched her neck, you should have backed off, not dove right in to make the woman scream. Your thought that, "She's got some phlebitis. Nothing I can do for it tonight, she's already anti-coagualted." Wasn't that helpfull. As you went about your business, I kept an eye on you. I know that when I paged you again two hours later to report the patient was having some minor mental status changes, that you were sitting at the computer. You should have come to see the patient when you got up before you decided to go bronch Mr. S. In case you were wondering, I most certainly did page you three times while you were in with Mr. S. I will not be ignored!
When the patients lab values came back at 4am (did I mention that this patient was an extremely hard stick but that I was able to get blood myself, without paging you to do an arterial stick?!?!?) and her WBC count had jumped from 11.5 to 17.5 and I relayed this message onto you and you replied, "Yeah. So. It's 4am I haven't looked at lab values yet." THAT WASN'T COOL. Given this patients current condition and her history, you should have been in that room faster than lighting. I'm really happy that when you finally went in to assess the patient, after I followed you around like a lost puppy dog for 15 minutes, and you then touched the site and Goren puss came oozing out that I was standing right there to comment, "Phelebitis, hunh?" Boy did that comment feel good! Sorry it was inconvenient for you that you now had to culture the patient but maybe you should have thought about that hours ago when I first brought this to your attention.
I had to bite my tongue hard when you bitched and moaned about now having "another thing to do." Correct me if I'm wrong, isn't this your job? Oh yeah, that's right, my error. Someone made you take the MCAT's, apply to medical school, complete 4 years of medical school, apply to a residency program, and become a doctor. Seriously lady, get a grip.
after a quick prayer to the IV God's I managed to get an IV in this ladies arm so she could get her STAT dose of antibiotics. Did I gloat to you? NO.
I found it ironic that during AM rounds with the fellow you provided a beautiful narrative of the nights events...perfectly describing what YOU did, what YOU noticed, what YOU caught...weren't you the one who didn't even want to assess the patient?
So can you explain to me why you did nothing but complain about "the nurses" all night. Oh and FYI, I heard when you said, "The one with glasses (me)... She's ridiculously demanding and just doesn't get it. She couldn't. She's just a nurse". But I DO GET IT! I think you don't. Yes, I am a nurse and I'm not disputing that fact. However, I think you need to realize something. I'm not some dumb ass who says stuff to hear myself speak. Look lady, I've got an Ivy League education, perhaps better than your no-name medical school education, and I've had enough of your BS.
Do me a favor, actually two of them. First, shut up! Then, grow up! We're all here for the good of the patients, but if that's too much for you, I've got some bad news...you just wasted $250,000 on an education that isn't going to lead to a career.
Signed,
Nurse Kelly
(better thought of by you as "the relentless dumbass who clearly identified what was wrong with the patient hours before you even looked at the patient but isn't capable of making recommendations because she's just a nurse")
Wednesday, April 09, 2008
Entitlement?
I would like to think that I have not become a hardened bitch and or nurse Ratchet, but tonight there seems to be a whole lot of "WTF" going on.
Explain to me this, if you are going to refuse services, why did you bother coming to the hospital. Why did you seek treatment.
Pt X, 61 year old obese female, admitted s/p flame burns to chest and right upper extremity. Burns noted to be mostly 2nd degree with some 3rd degree around the areola of her R breast. Pt went to the OR 5 days ago for autografting, donor site was the R upper thigh.
Where to begin with this patient...
#1: She's been primarily bed bound due to her bulky splint and dressing for the past 5 days; she's obese.
*She's been refusing her heparin shots.
Yes lady, I know they hurt like hell, but would you rather throw a clot and have a stroke or a heart attack, or both and die?
#2: Her blood sugars have been well over 200.
*She's been refusing her insulin.
Yes lady, I hear you when you say you weren't "diabetic" before you came to the hospital; however, you also do not have a primary care physician, nor were you testing you blood sugar at home. Did I mention that sometimes the stress of a burn injury can induce a temporary rise in your blood glucose level. Do you understand that the tighter we control your sugars, the better you wounds will heal?
#3: She's mal-odorous (I'm being nice here).
*She's been refusing her morning shower.
Lady, you sweat profusely, you have a weeping donor site, you have large breasts and abdominal folds that need to be washed so you don't get a fungal infection that will inevitably spread to your freshly grafted wounds and then you will be here getting IV antifungals that will turn your urine orange and you will pitch a fit because we will have to put in a foley catheter in order to accurately examine your kidney and liver function due to the toxicity of the medications you will be taking. FOR THE LOVE OF GOD, TAKE YOUR DAMN SHOWER!
#4: She complains about the food.
*She's been gobbling up every last morsel we put on her tray and mooches off of others.
*Lady, I'm sorry: that you think the mashed potatoes are too lumpy , that the chicken isn't tender enough, that the tea is a basic blend and not something of the organic variety, that we use smuckers peanut butter instead of jiff, that we serve oatmeal raisin not chocolate chip cookies, that we have Splenda not Equal, that we use white eggs not brown ones, that lunch and dinner are served on plastic trays, and that we supply plastic not metal silverware (it;s not like we are serving fillet Mignon)-wait, let me apologize for that too. Honestly, this isn't a five star restaurant. There are sick people here. Tell you what, if you hate the food that much, lie back and I'll put an NG tube in you. We'll pump you with liquid nutrition, you won;t have to taste anything.
#5: She complaints about the linens.
*She refuses to use hospital linens and/or wear a hospital gown.
Lady, I'll cut you a little slack on this, I agree, I wouldn't really want to lie on sheets that had previously been covered in god knows what, but your complaining about the thread count is out of line. And the issue about the gown, give me a break! The gowns allow for easy access. I have to change your dressings twice a day, It's not fair that I be required to strip you down like someone who's dressed to venture out in a blizzard. Please, for the love of god, and the sake of the patients who are really sick, cut the crap, and wear the gown.
Am I being unreasonable? I get that being hospitalized is stressful. I understand that you have lost control of your environment, that you endure painful procedures, that you experience aggravating delays in care, and that you really want to go home, but please, work with me here. I'm trying my best. Try and make the best of the situation. I want you to heal so you can go home but if you fight me on all the little things, time is going to stand still.
Explain to me this, if you are going to refuse services, why did you bother coming to the hospital. Why did you seek treatment.
Pt X, 61 year old obese female, admitted s/p flame burns to chest and right upper extremity. Burns noted to be mostly 2nd degree with some 3rd degree around the areola of her R breast. Pt went to the OR 5 days ago for autografting, donor site was the R upper thigh.
Where to begin with this patient...
#1: She's been primarily bed bound due to her bulky splint and dressing for the past 5 days; she's obese.
*She's been refusing her heparin shots.
Yes lady, I know they hurt like hell, but would you rather throw a clot and have a stroke or a heart attack, or both and die?
#2: Her blood sugars have been well over 200.
*She's been refusing her insulin.
Yes lady, I hear you when you say you weren't "diabetic" before you came to the hospital; however, you also do not have a primary care physician, nor were you testing you blood sugar at home. Did I mention that sometimes the stress of a burn injury can induce a temporary rise in your blood glucose level. Do you understand that the tighter we control your sugars, the better you wounds will heal?
#3: She's mal-odorous (I'm being nice here).
*She's been refusing her morning shower.
Lady, you sweat profusely, you have a weeping donor site, you have large breasts and abdominal folds that need to be washed so you don't get a fungal infection that will inevitably spread to your freshly grafted wounds and then you will be here getting IV antifungals that will turn your urine orange and you will pitch a fit because we will have to put in a foley catheter in order to accurately examine your kidney and liver function due to the toxicity of the medications you will be taking. FOR THE LOVE OF GOD, TAKE YOUR DAMN SHOWER!
#4: She complains about the food.
*She's been gobbling up every last morsel we put on her tray and mooches off of others.
*Lady, I'm sorry: that you think the mashed potatoes are too lumpy , that the chicken isn't tender enough, that the tea is a basic blend and not something of the organic variety, that we use smuckers peanut butter instead of jiff, that we serve oatmeal raisin not chocolate chip cookies, that we have Splenda not Equal, that we use white eggs not brown ones, that lunch and dinner are served on plastic trays, and that we supply plastic not metal silverware (it;s not like we are serving fillet Mignon)-wait, let me apologize for that too. Honestly, this isn't a five star restaurant. There are sick people here. Tell you what, if you hate the food that much, lie back and I'll put an NG tube in you. We'll pump you with liquid nutrition, you won;t have to taste anything.
#5: She complaints about the linens.
*She refuses to use hospital linens and/or wear a hospital gown.
Lady, I'll cut you a little slack on this, I agree, I wouldn't really want to lie on sheets that had previously been covered in god knows what, but your complaining about the thread count is out of line. And the issue about the gown, give me a break! The gowns allow for easy access. I have to change your dressings twice a day, It's not fair that I be required to strip you down like someone who's dressed to venture out in a blizzard. Please, for the love of god, and the sake of the patients who are really sick, cut the crap, and wear the gown.
Am I being unreasonable? I get that being hospitalized is stressful. I understand that you have lost control of your environment, that you endure painful procedures, that you experience aggravating delays in care, and that you really want to go home, but please, work with me here. I'm trying my best. Try and make the best of the situation. I want you to heal so you can go home but if you fight me on all the little things, time is going to stand still.
Wednesday, April 02, 2008
where did the time go?
Holy cow, I've been a real nurse for 9 months.
It's unbelieveable.
Overnight, (okay, four years, $210,000, numerous lost social hours, and more bed pans than I can count) I became a nurse.
Yup, on July 5th I went from Kelly, student nurse/"wanna be R.N." to Kelly R.N./"scared shitless to enter the real world of nursing because now people's lives actually depend on what I do."
I had a little less than a month after "becoming a nurse" to let it settle in. Before I knew it, I was taking on new challenges as a nurse in the Burn Intensive Care Unit.
And now, for your viewing pleasure, "My Life As a Nurse from A-Z"
a) It's been long, it's been hard, it's been frustrating, it's been rewarding.
b) There have been tears of laughter and those of sorrow.
c) I've been covered in every bodily fluid imaginable.
d) I've successfully resuscitated someone;
e) I've stood by as a family withdrew care and I watched the monitor flatline.
f) I've had patients reinstill in me the reasons I became a nurse;
g) I've had patients who made me question every decision I've made over the last four plus years.
h) I've worked days, I've worked nights, I've worked overtime.
i) I've been awake for 42 hours straight;
j) I've slept for 18 hours straight.
k) I've held a patients hand to let them know I care.
l) I've been karate chopped at by an angry/violent patient crying out for attention.
m) I've sounded idiotic when I've called pharmacy and cannot pronounce the name of the antibiotic that I'm requesting.
n) I've saved a life when I noticed that the antihypertensive agent (hydralazine) was ordered instead of the antihistamine (hydroxyzine).
o) I've gone 14 hours without urinating; I've urinated non stop after 5 beers.
p) I've missed out on parties/dinners/movies/social gatherings becuase of working night shift;
q) I've had 8 days off from work without ever having to take a vacation day.
r) I've been asked out by a patient
s) I've seen some mighty cute doctors roaming the halls.
t) I've passed gas in a patients room
u) I've been covered in every bodily fluid imaginageble (whoops, already said that one).
v) I've seen more male genetalia that all of my "promiscious" friends combined
w)I've sen what gravity does...NONE of us want to age.
x) I've stood in the med room talking to myself about what I need to do
y) I've talked to family and loved ones about death
z) I've come a long way, but my journey is just beginning.
Thanks for all the support along the way. Now hold on tight, this is only the warm-up!
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.
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.
Friday, March 21, 2008
ready-set-go
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.
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.
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