Success

For two days, I took care of a man who has what is probably some kind of microvascular disorder. The tips of his fingers and toes are black and essentially dying, and it causes him a great deal of pain. For two days, I administered very potent IV pain medication to him every two hours. Even that wasn't enough to control his pain, but on the second day, his primary resident had the day off and the covering doctor didn't want to change the pain management regimen. Finally, yesterday, I received orders changing his regimen to a long-acting oral morphine pill with some IV medication for breakthrough pain. I was so happy that they were changing him over to the long-acting agent he needed, but the excitement was short-lived when I realized that the dose they were giving him was FAR lower than he needed. I went to speak to the doctor immediately. He was very polite to me, but explained that a lot of thought had gone into the orders and that they had very carefully calculated how much medication they were giving him. "In fact," he told me, "this is a little more than he was getting before." As patiently as I could, I told him that I thought his calculation was wrong. He insisted he was right. I proceeded to sulk myself back to my patient's room, where I did the calculation for myself. I paged the doctor with my calculation, and the next thing I knew, I had new orders that were correct AND gave the patient more morphine equivalent than the previous day. Julie: 1, Doc: 0. Did I get thanked for it? Of course not. But it sure did feel good.

Patients are not pincushions

The drawing of blood in the hospital is organized by an incredibly complex system. We have phlebotomists who draw blood at specified intervals throughout the day, and if a physician decides that they want something drawn at another time, they generally have to do it themselves. Unfortunately, they do not have access to the Omnicell, which is like a giant system of lockers that store supplies for patients. That means that nurses have to fetch the supplies when they need them. A while ago, I took care of a man who was about 50 and had had a massive stroke earlier in the year. It left him bed-bound, unable to speak, and unable to perform fine motor movements. For some reason, the phlebotomists were unable to draw his blood in the morning. I still don't know whether it was because they couldn't find a vein or because the patient wouldn't hold still.

Later, in the busiest part of my morning, an intern (it was her third week as a doctor) came up to me and said, "I need to draw blood from your patient." "OK--what do you need?" In a "you're an idiot" voice, she said, "The stuff to draw blood." I said, "I realize that. What tubes do you need?" Again, in the idiot voice, "the stuff to draw blood!" At this point, I'm about to walk away, but I tried to give her the benefit of the doubt and asked, "what labs are you drawing?" She told me what she needed, and I went to get the supplies. When I returned, she looked at the supplies with a puzzled look and asked that I put the pieces together. Frustrated, I did it. Then she asked me to come into the room and help her. Begrudgingly, I agreed.

The doctor proceeded to begin to tie a tourniquet directly over my very tenuous IV. Yelling out, I told her that if she wanted to draw blood from that arm, I'd have to stop the IV fluids. Also, "could you please not tie the tourniquet right over the IV?" I stopped the fluids while she moved the tourniquet. She then took out the needle and successfully got the patient's vein. Then, she asked me what to do next. I stood, horrified, when I realized that she had no idea what she was doing, and it was too late to do anything about it, because the needle was already in the patient. Annoyed, I explained what to do. I was extremely irritated that she clearly had no idea what a vacutainer was or how it worked. Trying times, I tell you.

As a side note, as soon as she stuck him, he moved his arm. She kept yelling at him to please stay still, progressively getting louder while I got more and more annoyed. Finally, I told her, "yelling louder won't make him stay still. He can't follow your directions." When she yelled at him one more time, I lost it and said, "this patient cannot follow your directions. Do you know your patient at all?!"

Unfortunately, the vein she successfully stuck blew after the first tube of blood. The intern removed the needle from the patient and the patient's hand started dripping blood. Silly me, I had figured that since I had gotten her all the supplies she needed, she might have pulled out a bandaid and/or piece of gauze. The patient bled on the nice new sheets we had made the bed with. I couldn't help but make an obnoxious comment about how we'd have to fix them. In the meantime though, the intern was waving around an open needle. Waving is no exaggeration--my nursing student and I had to literally bend back a few times to avoid the swinging needle. Finally, I held my hands in front of me in a guarding-type position and I asked her, "can you please just cap that needle?" She ended up capping it with this tiny little plastic tube that initially covers the needle when you take it out of the package rather than the safety device that is attached to the needle itself. This caused me to release another scream, because she looked dangerously close to poking herself! She looked at me in an annoyed fashion and asked what was wrong. "You should NEVER cap a needle like that. It has a SAFETY device on it." Her excuse was that she didn't know about the safety device. My response: "We are here to take care of patients. One way we DON'T take care of patients is by treating them like pincushions and using equipment we don't know how to use on them. Where is your senior??" I told her not to draw any blood on any of my patients (and hopefully any others) until she knew how to do it before walking into the room. She said, "am I stressing you out?" "Uhh...yeah!"

Now, there was still that second tube of blood to draw. Because I was clearly so angry, the intern asked me if I would do it. While I technically could, none of the nurses ever draw blood on patients because we'd be asked to do it alllllll day otherwise. Nothing else would get done, and doctors would never learn how to properly order their labs for the phlebotomists. So I said no. She gave me an attitude, but she finally got the job done. Lucky for that intern, I haven't seen her on the floor since.

The following two incidents happened a while ago, but took so much out of me that I haven't been able to bear re-hashing them until now...

A patient who is dying of pancreatic cancer has been admitted to our floor a few times. His wife is, of course, devastated and isn't coping well at all. Essentially, nothing that anyone does for her or her husband is ever enough or satisfactory. Objectively, I realize that this is her way of dealing with losing control over her life and her husband's illness, but boy can it become frustrating. She was constantly lurking the halls, waving down any passing nurse for one thing or another. She had honestly become such a bother that her husband, the actual patient, was getting pretty sick of her and her antics. On one particular day when I was in charge, a coworker of mine was taking care of this patient. His wife came in, and when she did, the patient rolled his eyes and looked the other way. The patient had been scheduled for a CT that day, and the wife was getting herself worked up about why he was going for this exam. Right as this was happening, transport rolled up with a cart to take the patient down to CT. When my coworker announced their arrival, the wife freaked out and demanded to know why he was going down and begged for the test to be rescheduled. While this seems like a fairly simple thing to do, it's not at all, so Kim left the room for a minute to see if she could rearrange things. When she returned, she found one of our oncologists in the room, prying a handful of pills from the wife's hands while she threatened to take them all and kill herself. None of us have ever been presented with such a situation before (someone in the hospital who is not an admitted patient but requires immediate intervention), but luckily everyone teamed up and made a number of important phone calls that brought all the right people together within about 10 minutes. We had our nurses, the patient's medicine attending, a psychiatric resident, the psychiatric nurse liason, security, and a few others on board. Risk management had been called, and the plan was to calmly explain to the patient's wife that we needed to take her down to the ER to get a psychiatric evaluation. If she refused or put up a fight, security was going to have to forcible take her there. At first she refused, but eventually agreed to walk herself down there with this team of professionals escorting her. Then, of course, we are stuck with trying to decide whether the patient is safe to go home with her. For better or worse, she got cleared by psych and the patient actually went home with her later that day.

Made my day

So I started this blog after I was on a flight where I helped a passenger who was in need of medical care. At the time, one of the flight attendants took my driver's license and copied down my information. While my assistance was not motivated by any reward, I did wonder whether I'd get anything from the airline. It is now almost 2 months later, and I got an e-mail this morning from the Director of Medical and Occupational Health Services at American Airlines. They're giving me 15,000 miles!! I'm so excited :)

Bedside manner

This morning was an interesting one. After the night nurse gave me report on what happened overnight with my patients, I went to say hello to them. I walked into my first patient's room to find a doctor I had never met in there. This didn't exactly surprise me, as all new doctors started on July 1st. I was shocked, however, to learn that this particular doctor was the patient's attending physician, since he didn't look a day over 20. In any case, the patient had a few questions for him, none of which he could answer. He told the patient, "to be honest, I had the day off yesterday. I like to see my patients first thing in the morning, before catching up on all the notes that were written yesterday, so that I can address any emerging issues as quickly as possible, so I'll have to get back to you about the answers to your questions." The patient looked puzzled. The doctor repeated what he had said about seeing his patients before reading the charts, and then followed up with the following. "You see, one day in my residency, I came in in the morning only to discover one of my patients totally confused and we had to send him to the ICU! That's why I like to see the patients first, charts second." The patient didn't say much, but appeared to accept his explanation, and the doctor left. I spent a minute with the patient, catching up on what had happened overnight, and then went to check on my other patient.

When I walked into my second patient's room, the same doctor was there. Essentially, the same exact thing happened. She had a few questions for him, he couldn't answer them, and told her he'd have to come back later after reviewing her chart. She looked puzzled. She asked her questions again. The doctor said, "Can you imagine? One day in my residency, I walked into my patient's room in the morning and found her dead! That's why I like to see my patients before I look at the chart." The patient's eyes nearly bugged out of her head. She was brave enough to say "was it really necessary to tell me that?" He caught himself for a moment, and tried to relieve her by saying, "well, we expected it for her. Not for you!" My patient was not amused. She said again, "did you really need to tell me that?" The doctor kind of brushed it off and left. Again, I stayed behind to catch up with her and she could not stop talking about what he had said. "Where did he go to medical school? What kind of bedside manner is that? He's a nut!" Throughout the remainder of the day, she kept asking me about him and kept insulting his bedside manner. While I was also pretty appalled by these two discussions, I'm almost looking forward to my next interaction with this guy.

The double threat

Before I went to nursing school, I knew that I had trouble handling vomit. I worked at a clinic where I encountered a lot of people vomiting, and for weeks I'd gag every time they did. I finally got desensitized to that and was able to function like a normal human being while at the clinic. Unfortunately, a lot of time passed between stopping work at the clinic and encountering more vomiting patients, and I was resensitized to vomiting. While in nursing school, I also learned that I had serious problems handling poop, and feared that I might not make it as an actual nurse because of this problem. My med/surg clinical instructor even recommended that I work on a surgical floor because "those people never poop!" Since working as a nurse, I've gotten a lot better at handling bodily fluids and excrement, but still struggle at times. Yesterday was one of those times.

I took care of a patient who has a large abdominal mass that is keeping her from digesting her food properly. At this point, she hasn't taken anything by mouth in weeks. She was supposed to go for surgery on Friday, but due to a series of mishaps, she didn't get the surgery. She did, however, get her nasogastric tube (tube going into the nose down to the stomach that sucks out all contents in patients with this problem) removed that day. She was so incredibly relieved to have it out that even when she found out that she wouldn't have the surgery, she told the doctors that she'd rather vomit than have the tube reinserted. She made it from 5pm on Friday to 3pm on Saturday without puking. At 3 though, she barfed up a bunch of green crap. My major difficulty in handling fluids like this is the requirement to measure them, which means pouring them out into a graduated containter. As if the vomit didn't smell bad enough, pouring it out really made me wretch. I gagged a few times and thought I had it under control. I was holding the container of vomit as far away from my face as possible, in the bathroom, while I ducked my head out into the hallway in an attempt to breathe fresh air. The gagging would not cease, however, and I ended up puking in my patient's garbage can. For all the problems that I've had with gagging due to gross things, this was a first. Way to go...

Drama

A woman had been on our floor for what seems like weeks. She had a history of bipolar disorder, I believe, and she required a 24-hour sitter because she was very confused and would pull at lines and things like that. She often called people nasty names. Sitters are an annoyance, even though they ultimately protect a patient's safety, because they're not provided by the hospital. You have to take someone out of your own staffing to fill the need. That means that you're usually short-staffed when there's a sitter case on the floor. Anyway, as I recall, this patient had had a hip replacement, but the site got infected so they removed the hardware. She was being treated with antibiotics and laid around with no hip joint. On the night shift, while helping to reposition the patient, one of our techs discovered a large pool of blood at her hip site. We ended up calling a code because she was quickly bleeding out. All of a sudden, she became remarkably lucid and was screaming, asking who was going to intubate her, where anesthesia was, etc. A doctor in the room tried to distract her and calm her down, at which point the patient started demanding who that doctor was. When the nurses tried to distract her from that, she started yelling, "No! Who is she? Black glasses, blonde hair. Black glasses, blonde hair!" No one could help but chuckle at the change in the patient's mental status despite the emergent situation.

One of the scarier things that's ever happened to me was when I was taking care of a man with Parkinson's disease. We'd had a very calm morning when I received orders to basically quadruple the amount of the drug he was getting to treat the Parkinson's. I suspected that this was an error, so I paged the doctor to clarify the order. Even though it took a while to receive a response, I confirmed that the new order was correct. Clearly I wasn't the only one to think the order was strange because the pharmacy didn't approve the order for hours. The lack of their approval prevented me from taking the pills out of the medication dispensing machine, so I was stuck. I called the pharmacy to find out why they didn't approve the drug. They said they were waiting to hear back from the ordering physician because the order seemed to strange. I told them that I had spoken to the physician and it was correct. I gave them the physician's pager number to try them again. The order ended up getting approved, and I gave the next dose. About two hours later, the patient went completely unresponsive. His vitals remained fine, but because no one could figure out what was going on, we sent him to the ICU (where, by the way, they continued to give him the drug according to the same order). He ended up getting discharged the following day after waking up and having no problems. He said he remembered the commotion, but wasn't able to respond (I can't imagine anything scarier...). I spent the whole day in agony, thinking I had made the wrong decision to give him the drug despite all my efforts to verify the correctness of the order, but I'm just glad he ended up being fine.