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.

Bodily fluids

Last week I was asked to speak on a panel of nurses who had 1-2 years of experience for the nurse residency program at my hospital. Here are a few past events that I thought of as a result of our discussion.

Grossest things I've ever seen:
One time, I took care of a woman who had breast cancer that had metastasized to her brain. I'll always remember her for two reasons. One was this horrendous day she put me through once that all had to do with her taking a shower. The other was a time on a different admission when her health was rapidly declining. Another nurse was taking care of her when she started seizing and was having a lot of difficulty breathing. We called a code and the usual chaos ensued. I noticed that a pool of liquid diarrhea was pouring out of the back of her diaper and collecting below her, so I warned everyone involved so they didn't get covered in the mess. A general surgeon was attempting to insert a central line in her groin. He had tried a few times without success, so he moved to the other side to try there. With his sterile gloves, he pushed aside her diaper and the diarrhea came pouring out there too. He wiped it away with the gloves and successfully put the line in that site. Luckily, he told the ICU nurse that came to transfer the patient, "That line needs to be changed ASAP. It's far from sterile."

More recently, I took care of a woman with colon cancer who has recurrent bowel obstructions, which means that she vomits all the time. This means that her potassium is always low, because she keeps losing it by throwing it up. I received an order to give her some oral potassium pills to replace her losses. I asked if the doctor would be willing to change it to IV form, because I imagined the likelihood of the pill ever getting absorbed was pretty slim. They wanted to try the oral form first, so I brought it in to her. She took the med cup from me, and as she moved it toward her mouth, she slowly said, "I'm feeling a little nauseous..." before projectile vomiting. I had to jump out of the way to avoid being hit by the stream of vomit. It went so far that it actually hit the opposite wall! I've never seen anything like that. And as if that wasn't enough, she did end up getting over a liter of it into a bucket. When I poured it out into the toilet, I saw some whole pills in it. One was bright red, which I didn't recognize. I asked her what it was, and she identified it as one she hadn't taken in over three weeks. Yikes!

Julie, Flight Nurse

I had some excitement on my flight back from Boston this morning. As I'm sitting calmly in my seat about midway through the flight, I see a flight attendant get what looked like an AED out of the overhead bin in the front of the plane and head to the rear of the plane. I didn't hear any commotion or call for help, so eventually I figured it must not have been an AED. About 5 minutes later, they did overhead a call for nurses and doctors, so I jumped up and headed to the back of the plane where there was a man leaning over the back of one of the seats. A flight attendant told me he was really nauseous and sweaty. I asked if he was diabetic, and he said yes. I promptly asked the flight attendant for some orange juice, and tried to figure out where this man's baggage was so we could get his glucometer. This was not an easy process, so I called out to the other passengers to see if anyone had one. No response. By this time, a doctor had come to help. Eventually, the man was able to tell us where his bag was, so we got out his glucometer and other meds. My hands were shaking badly as I desperately got his accucheck. It turns out that his blood sugar was actually really high, so he felt much better after giving himself some insulin. Throughout this ordeal, the flight attendant was asking the doctor and me to tell her if we needed to land the plane due to medical emergency. The guy didn't have any chest pain or other symptoms of a heart attack, so he seemed to be in the clear. When we landed in Chicago, there was an ambulance waiting for us and EMTs got the guy off first. As I deplaned, I heard them trying to convince him to go to the hospital to get ruled out for an MI, but who knows what happened after that.

Swine flu

Oh! And we had our first confirmed case of swine flu on the floor today!

New leaf

Putting aside the fact that I haven't blogged since 2006, I'm going to try to write a nursing blog. You know, just the weird and crazy and funny stuff. I love the fact that the title of the blog, which I had created while working at the SIC in college, remains humorously appropriate.

I work on a medicine and oncology unit at a large, teaching, university-based medical center. We have 37 beds on the floor, and for at least a year now, we've been solidly full. This is both a good and bad thing. It means we keep our jobs in a shitty economy, but it also means that morale is slightly down, energy reserves are becoming diminished, and we're seeking sicker and sicker people. This, of course, creates more and more work. Were it not for my fantastic colleagues, I'd have been out of there months ago.

Today I worked an 8-hour shift, which is pretty abnormal for me--I usually work 3 12-hour shifts per week. I took care of four patients--two of whom I had taken care of yesterday. One of those patients is a man who has lung cancer that has spread to his liver. He came in with a high calcium level, which is common in cancer patients. Yesterday, he said a few things that didn't make much sense, but overall, was fine. Today, though, he told me we were in an oil tank that was about to explode and thought it was 1925. He'd already pulled out two IVs overnight and got up from bed by himself about 4 times in 30 minutes, even with the bed alarm on. This left me with only one choice--to restrain him. I strapped him down in a vest restraint that attaches to the bed to keep someone from getting up alone. Within 10 minutes, he was begging me to take it off. Not because he knew that I had tied him up, but because "I need to be able to get out of here if this place blows up!!"

The other patient is severely demented woman who spent a month of the geriatric psych unit for a month before coming to my floor to be ruled out for a stroke. The woman spends a few hours a day babbling on to herself. She doesn't make any sense, can't answer questions, and can't follow commands. She doesn't move herself at all, which means that part of my job is to turn her in bed every 2 hours to prevent the development of bed sores. In any case, with any type of care like this that involves touching her, she claws, swats, hits, and grabs at me while screaming obscenities. As long as you can avoid taking this kind of abuse personally and avoid injury, it becomes quite amusing.

Also on the floor were two other jewels. One is a very young man, in his early twenties, in the hospital with a sickle cell crisis. He keeps peeing in the bed and calling for the nurse to change it even though he is able to pee in a urinal, or in the plain old toilet. Now what kind of cognitively intact young man wets the bed?! Of course, his nurses are quite frustrated with him and have spoken pretty harshly to him in an attempt to change this behavior. Yesterday, a few of the techs went in to speak to him after we learned that this guy has a girlfriend. "Do you piss in the bed when you're sleeping with your girlfriend?!" No bed-wetting since.

Another man has threatened violence to the nurses a number of times since his admission. He's also told the nurses about a number of people he's going to "get" upon discharge. We've called security a few times, but this morning the nurse was ready to get the police involved. The patient told her he had a gun under his pillow. After a search by security though, no gun was found. At that point, he told her he would strangle her with some ace wraps.

Just another day at work...