People deal with hospitalization in different ways. Some are patient and forbearing, some have taken that horrible advice from Reader's Digest et. al. ("What Your Doctor Isn't Telling You!" "10 ways to INSTANTLY GET WHATEVER YOU WANT IN HOSPITALS!" etc) and hope that by being the "squeaky wheel" they'll get better "service". Some prefer to take a different tack; or their families do:
I was in a patient's room this morning, my last shift of orientation. The patient was in A LOT of pain. Seems he'd been taking a few more painkillers at home than he had reported initially...oh well, too late to deal with that, it happens. I'm hooking him up to a different opioid for his PCA, and he's moaning in pain, writhing around, refusing to look at/deal with/acknowledge his colostomy (why is it always men who act like someone else is going to change/empty the damn thing forever?), and he says "god i hate people to see me like this!!!!"
Dude...i sympathize. I would rather have all SORTS of pain than have someone LOOK at me while i'm in it- but then his girlfriend (the 50 year old wearing the tweeny bopper sweatshirt)turns and goes "oh honey...it's okay...she's not people...she's just the nurse. she's nobody".
And I got just a little pissed off. I know people deal with pain and stress in different ways. Get mad at me. Swear a blue streak. Remind him that I'm pretty much cool about pain- dude had one HELL of a midline incision...he can get whatever he wants to numb that sucker- see it all the time, he's not my first guy in pain. But please PLEASE don't tell him "she's nobody". That sort of thing encourages people to treat us as interchangeable cogs in a wheel. As brainless automatons. As less than the professionals we are. I was in their changing his meds BECAUSE I CHASED DOWN HIS DOCS AND SUGGESTED THEY CHANGE HIS ORDERS TO A MED I THOUGHT MIGHT WORK BETTER FOR HIM.
But hey- who am I to argue- i'm Nobody.
Saturday, October 22, 2011
Tuesday, October 18, 2011
They Tried To Make Him Go To Rehab...
I just worked my first two night shifts. They were back to back. At their conclusion I am officially OFF orientation...eek. Also, my "white cloud" status is GONE. Friday night, on report I was given Mr. Detox.
"Mr. Detox is a middle-aged man, who had a lung procedure done. Past history of ETOH abuse...yadda yadda yadda. He's on the Ativan Scale".
For those of you playing at home, the Ativan Scale uses vital signs, plus measurements like "twitchyness" and "sweatiness" plus how much the patient is awake, and how many times he gets out of bed, to come up with a measure of how much he is detoxing. This is done every 2 hours. Ativan is administered accordingly.
"I haven't been giving Mr. Detox very much ativan, because I fear that it makes him MORE loopy"
Alpine: "wait...you think the ativan is making him WORSE? how much are you giving?"
Dayshift: "Just...like...one mg every two, but he just keeps getting MORE agitated!"
Alpine: "oh...goody."
Needless to say, Mr. Detox needed a LOT more than 1mg q2hrs. He was literally BOUNCING around the room, pulling on his chest tube, pulling off his pants, trying to "visit other people in their rooms", gnashing of teeth, tearing of hair. By hour 4 I was calling the doc every 10 minutes, begging for more ativan. My preceptor freely admitted that she's afraid of detoxers and of giving too much ativan. Me, I've seen the amounts given in the ED for acute detox, and I knew we could go A LOT higher, considering that 4mg IV Ativan PLUS 10 MG HALDOL all administered AT THE SAME TIME put him out for...5 minutes. Before he started bouncing again.
It was getting to the point where I was expecting a seizure at any moment, and his temp was climbing. I pulled the plug right there: "Night Preceptor? I want a Stepdown Unit transfer. This isn't safe." The only reason we were able to keep it up till 1 am was that there were TWO of us, so we somehow managed to keep everyone else safe while sitting on him.
He's still in Stepdown. So...good call on our part.
Moral of the story: If they tried to make him go to rehab, but he said "no!", GIVE MORE ATIVAN :-p
"Mr. Detox is a middle-aged man, who had a lung procedure done. Past history of ETOH abuse...yadda yadda yadda. He's on the Ativan Scale".
For those of you playing at home, the Ativan Scale uses vital signs, plus measurements like "twitchyness" and "sweatiness" plus how much the patient is awake, and how many times he gets out of bed, to come up with a measure of how much he is detoxing. This is done every 2 hours. Ativan is administered accordingly.
"I haven't been giving Mr. Detox very much ativan, because I fear that it makes him MORE loopy"
Alpine: "wait...you think the ativan is making him WORSE? how much are you giving?"
Dayshift: "Just...like...one mg every two, but he just keeps getting MORE agitated!"
Alpine: "oh...goody."
Needless to say, Mr. Detox needed a LOT more than 1mg q2hrs. He was literally BOUNCING around the room, pulling on his chest tube, pulling off his pants, trying to "visit other people in their rooms", gnashing of teeth, tearing of hair. By hour 4 I was calling the doc every 10 minutes, begging for more ativan. My preceptor freely admitted that she's afraid of detoxers and of giving too much ativan. Me, I've seen the amounts given in the ED for acute detox, and I knew we could go A LOT higher, considering that 4mg IV Ativan PLUS 10 MG HALDOL all administered AT THE SAME TIME put him out for...5 minutes. Before he started bouncing again.
It was getting to the point where I was expecting a seizure at any moment, and his temp was climbing. I pulled the plug right there: "Night Preceptor? I want a Stepdown Unit transfer. This isn't safe." The only reason we were able to keep it up till 1 am was that there were TWO of us, so we somehow managed to keep everyone else safe while sitting on him.
He's still in Stepdown. So...good call on our part.
Moral of the story: If they tried to make him go to rehab, but he said "no!", GIVE MORE ATIVAN :-p
Wednesday, October 12, 2011
Buddha is my co-pilot (actually, my preceptor)
I may have mentioned this before, but I have the best preceptor in the whole wide world. She actually has me call her "Buddha", because she is, well, Buddha-shaped. Also jolly. She's been a nurse for 35 years, and she knows pretty much all there is to know about surgical nursing. (She also stands up for me to just about EVERYONE- even the manager, the director of surgical nursing, you name it. She doesn't let ANYONE mess with her "babies"...it's like the OPPOSITE of nurses eating their young.)
Today we had The Patient Assignment From Hell...
Our floor is a pretty high-acuity med-surg floor...primarily Gen Surg (bowel surgeries, esophageal stuff, the occasional weird pancreas thing), Thoracic (chest tubes! And stents! wheee!) and Transplant (kidneys and pancreases only, ifyouplease, unless you had one elsewhere, and are rejecting...). But when Frozen Northlands Teaching Hospital gets busy...we get everything. Urology. Trauma. Orthopedics. WhateverTheFuckThatServiceDoes. We can to 3 kinds of drips, for the most part: Heparin (per protocol, q5hr aPTT draws...huuuuge pain in the neck) Diltiazem (lots and lots and lots of HR checks, and BP checks...like, q1hr or q30min) and...Insulin (q30min finger sticks and rate adjustments. Guess what we had? If you said "ONE OF EACH! PLUS WOUND VACS! AND THE OTHER TWO WERE DIABETIC TOO!!!" you'd be right.
The charge nurse actually APOLOGIZED for putting together the Patient Assignment from Hell, but those were the open beds, because that's who we managed to discharge. I was seriously hyperventilating a few times, even with Buddha at my side, nimbly assessing and cranking drips up and down. While helping me trouble-shoot the 2 blocked JP drains, and the wound vac's low-pressure alarm...
She just says "Easy Tigger (she REFUSES to call me "Alpine")! Take it down to Mach 4! This isn't the ER!" then she smacks me upside the head and tells me to go get coffee before i fall over...
We (I, officially) had a 5 pt. assignment, which is standard.
Today we had The Patient Assignment From Hell...
Our floor is a pretty high-acuity med-surg floor...primarily Gen Surg (bowel surgeries, esophageal stuff, the occasional weird pancreas thing), Thoracic (chest tubes! And stents! wheee!) and Transplant (kidneys and pancreases only, ifyouplease, unless you had one elsewhere, and are rejecting...). But when Frozen Northlands Teaching Hospital gets busy...we get everything. Urology. Trauma. Orthopedics. WhateverTheFuckThatServiceDoes. We can to 3 kinds of drips, for the most part: Heparin (per protocol, q5hr aPTT draws...huuuuge pain in the neck) Diltiazem (lots and lots and lots of HR checks, and BP checks...like, q1hr or q30min) and...Insulin (q30min finger sticks and rate adjustments. Guess what we had? If you said "ONE OF EACH! PLUS WOUND VACS! AND THE OTHER TWO WERE DIABETIC TOO!!!" you'd be right.
The charge nurse actually APOLOGIZED for putting together the Patient Assignment from Hell, but those were the open beds, because that's who we managed to discharge. I was seriously hyperventilating a few times, even with Buddha at my side, nimbly assessing and cranking drips up and down. While helping me trouble-shoot the 2 blocked JP drains, and the wound vac's low-pressure alarm...
She just says "Easy Tigger (she REFUSES to call me "Alpine")! Take it down to Mach 4! This isn't the ER!" then she smacks me upside the head and tells me to go get coffee before i fall over...
We (I, officially) had a 5 pt. assignment, which is standard.
Mistah Unknown
Night Shift:"Your patient in room 3 is Mister Unknown...pronounced "Unknown""
Alpine: "Um...wait...why doesn't he have a name? Isn't he conscious? Don't we ASK them when they regain consciousness what their names are?"
Night Shift: "Well...yes...but...:sighs: read his chart. He refuses to tell us. Trust me, Alpine, you're going to LOVE this one!"
Alpine: "okaaaaaaay"
So I sat down and read his chart. Mr. Unknown ("Unk" to his friends) is 19ish. As teenage males are wont to do, he gets drunk...and high...and then steals a car...but since this is the rather sparsely populated Frozen Northlands, the cops don't have much to do some evenings. So they chased him. He, naturally, failed to make good his escape. He had LOTSA injuries. A Random Sampling: two collapsed lungs (yeah, that's both of em), bruised spleen, lacerated liver, lacerated kidneys, perforated bowel, and broken leg. He fled the scene on foot, naturally.
So I'm, like, in AWE of this dood- i mean, you have to be at least MODERATELY badass to flee the cops with all your internal organs misbehaving, and a broken leg. But apparently he used up ALL his badassery. Cause in I walk:
Alpine:"Goodmorning Mr Unknown! I'm Alpine, and I'll be your nurse today!"
Mistah Unknown: "fuck you bitch! let me sleep! And give me some pain med'cine!"
Alpine: oh HELL no...he did NOT just say that! "Mr. Unknown...you do not get to speak to the nursing staff like that...if you find your care here to be inadequate, I'll be more than happy to arrange you to be transferred...TO PEDIATRICS!"
Mistah Unknown: "sorry miss...i wont do it again!" (he didnt...btw)
Alpine: "So...would you mind telling me your last name? It's going to be extremely odd calling you 'Mister Unknown' all day..."
Mistah Unknown: "HELL NO! This way the cops wont find me!"
I didn't have the heart to point out to him that he listed BOTH HIS PARENTS as his emergency contacts. With, naturally, their first and last names. I just smiled and went about my day. He spent the whole day asking us to dial outside numbers for him so he could speak to his "friends and his girl"...and then getting pissed and hanging up on them...then immediately ringing the call bell for us to call them back "so they can apologize to him"...seriously, the guy was acting like he was 7!
Alpine: "Um...wait...why doesn't he have a name? Isn't he conscious? Don't we ASK them when they regain consciousness what their names are?"
Night Shift: "Well...yes...but...:sighs: read his chart. He refuses to tell us. Trust me, Alpine, you're going to LOVE this one!"
Alpine: "okaaaaaaay"
So I sat down and read his chart. Mr. Unknown ("Unk" to his friends) is 19ish. As teenage males are wont to do, he gets drunk...and high...and then steals a car...but since this is the rather sparsely populated Frozen Northlands, the cops don't have much to do some evenings. So they chased him. He, naturally, failed to make good his escape. He had LOTSA injuries. A Random Sampling: two collapsed lungs (yeah, that's both of em), bruised spleen, lacerated liver, lacerated kidneys, perforated bowel, and broken leg. He fled the scene on foot, naturally.
So I'm, like, in AWE of this dood- i mean, you have to be at least MODERATELY badass to flee the cops with all your internal organs misbehaving, and a broken leg. But apparently he used up ALL his badassery. Cause in I walk:
Alpine:"Goodmorning Mr Unknown! I'm Alpine, and I'll be your nurse today!"
Mistah Unknown: "fuck you bitch! let me sleep! And give me some pain med'cine!"
Alpine: oh HELL no...he did NOT just say that! "Mr. Unknown...you do not get to speak to the nursing staff like that...if you find your care here to be inadequate, I'll be more than happy to arrange you to be transferred...TO PEDIATRICS!"
Mistah Unknown: "sorry miss...i wont do it again!" (he didnt...btw)
Alpine: "So...would you mind telling me your last name? It's going to be extremely odd calling you 'Mister Unknown' all day..."
Mistah Unknown: "HELL NO! This way the cops wont find me!"
I didn't have the heart to point out to him that he listed BOTH HIS PARENTS as his emergency contacts. With, naturally, their first and last names. I just smiled and went about my day. He spent the whole day asking us to dial outside numbers for him so he could speak to his "friends and his girl"...and then getting pissed and hanging up on them...then immediately ringing the call bell for us to call them back "so they can apologize to him"...seriously, the guy was acting like he was 7!
Friday, September 16, 2011
Please, PLEASE dont do that sir!
The last 7 (yes, 7) shifts have seen me taking a full (5) patient assignment. I'm psyched, and a bit shaky still, but my preceptor assures me that i'm safe to practice. The hardest part has been that ALL SEVEN of these shifts have been with a patient I'm going to call "Doctor Evil". This is because of a physical resemblance. He is not a doctor. This is important. What he IS is a Maunchausen's patient. This man hurts himself to get surgeries by infecting wounds by putting things in them. He is the patient from hell. Usually I'm pretty zen about my patients. I can't choose them, I can't alter their lifestyles, so I just accept it. But this man decided to make ME PERSONALLY a part of his health-care fantasy. And that is not ok.
He has been in the hospital for, cumulatively, several YEARS of time. So he knows the drill. And he knows how the machines work. So as soon as I would leave the room, having hung a bag of antibiotics...the pump would alarm. And for the first TWO DAYS I thought that I was forgetting to unclamp things...or the antibiotic would mysteriously not have run in...necessitating me standing in the room troubleshooting for half an hour.
One of the other nurses finally realized that he was basically gaslighting me to get attention. That was when I decided I strongly disliked my patient.
So he's been making work kind of hellish, with constant demands, and inappropriate sexual innuendos aimed at myself and the other nurses. But, as my preceptor says..."if you can handle Dr. Evil, you can handle ANY patient".
He has been in the hospital for, cumulatively, several YEARS of time. So he knows the drill. And he knows how the machines work. So as soon as I would leave the room, having hung a bag of antibiotics...the pump would alarm. And for the first TWO DAYS I thought that I was forgetting to unclamp things...or the antibiotic would mysteriously not have run in...necessitating me standing in the room troubleshooting for half an hour.
One of the other nurses finally realized that he was basically gaslighting me to get attention. That was when I decided I strongly disliked my patient.
So he's been making work kind of hellish, with constant demands, and inappropriate sexual innuendos aimed at myself and the other nurses. But, as my preceptor says..."if you can handle Dr. Evil, you can handle ANY patient".
Monday, August 29, 2011
Patient Advocacy
As a nurse, what is arguably one of the most important things I can say in the course of my everyday job?
"This doesn't look/feel/seem quite right!!!"
Two days ago, still on orientation on a busy floor, I had a patient who had come in after Very Bad Things had happened to his esophagus. He was two weeks or so PAST the Very Bad Thing, but he was still "a little out of it" and his cough sounded...funky. It was my first day of two with this patient, and I was reassured on day one that his coughing was related to the Very Bad Thing he had come in for. His diet was ordered as Full Liquids, so when his wife asked for a milkshake in the afternoon, I went and made one (i am fully in favor of making food for patients. They get calories, I get brownie points.)
The problem was, after his wife started feeding him, he started coughing milkshake colored sputum. This was especially worrying, as immediately BEFORE the milkshake, his sputum was NOT that color. "But he's had a swallowing test done!!!" insisted his wife.
So I paged my Favorite Resident (he's not only REALLY good at his job, and highly personable and respectful, he's HOT!) and he came over yesterday morning. "Swallow study? well he's had a test to see if there's a MECHANICAL problem (tumor, obstruction, etc)!"
Me: "Um...you mean nobody has done a Speech and Swallow Consult?" (Speech Language Pathology...they RULE- they can evaluate anyone to determine how they can communicate, and if they're safe to be fed)
Favorite Resident: "well damn...I'll order one for first thing tomorrow then...yeah...you're right...if this is a result of his Other Medical Problems, this could be something where he's going to need help..."
Me: "So...no more milkshake then???"
"This doesn't look/feel/seem quite right!!!"
Two days ago, still on orientation on a busy floor, I had a patient who had come in after Very Bad Things had happened to his esophagus. He was two weeks or so PAST the Very Bad Thing, but he was still "a little out of it" and his cough sounded...funky. It was my first day of two with this patient, and I was reassured on day one that his coughing was related to the Very Bad Thing he had come in for. His diet was ordered as Full Liquids, so when his wife asked for a milkshake in the afternoon, I went and made one (i am fully in favor of making food for patients. They get calories, I get brownie points.)
The problem was, after his wife started feeding him, he started coughing milkshake colored sputum. This was especially worrying, as immediately BEFORE the milkshake, his sputum was NOT that color. "But he's had a swallowing test done!!!" insisted his wife.
So I paged my Favorite Resident (he's not only REALLY good at his job, and highly personable and respectful, he's HOT!) and he came over yesterday morning. "Swallow study? well he's had a test to see if there's a MECHANICAL problem (tumor, obstruction, etc)!"
Me: "Um...you mean nobody has done a Speech and Swallow Consult?" (Speech Language Pathology...they RULE- they can evaluate anyone to determine how they can communicate, and if they're safe to be fed)
Favorite Resident: "well damn...I'll order one for first thing tomorrow then...yeah...you're right...if this is a result of his Other Medical Problems, this could be something where he's going to need help..."
Me: "So...no more milkshake then???"
Death
Sorry for not keeping up...everything moves so FAST in orientation! I'm up to 4-5 patients, which is a full load. I'm the first one in orientation to carry a full load and get out of work on time. Which kinda scares me- am I doing something wrong to get my work done on time? God I hope not. Yesterday I worked during the Hurricane That Wasn't. The nurse in the assignment next to me and my preceptor had a patient on Comfort Measures. She died. My preceptor thought it would be a Good Learning Experience for me.
Thing is, I've seen dead people before-both in clinical and in the field. This time though, there was a difference- our MD was a brand-new intern. Didn't know the patient, since she was only admitted that morning. And, while well-meaning, he's a bit hesitant (I'm sure it will wear off). He had to certify death. He didn't know how. We had to walk him through it, and then I helped prepare the body for the morgue. The patient had had false teeth. The postmortem checklist specifies that you must replace them BEFORE sending the body to the morgue, lest rigor set in, and cause the face to be stuck without its teeth. I really REALLY didn't want to be the one to put the teeth back- after all, what if the patient rose as a zombie?!? WITH MY FINGERS IN THE MOUTH!!!!
I don't know why, but that really stuck with me. My patient could rise as a zombie, and us without a SINGLE machete on the floor!
It was only after we'd put the toe tags on, and the body IN the bag and zipped it shut that he realized he'd never done the formal LEGAL certification of death. So I went and unzipped the bag, exposing the body. He asked me not to leave the room, and help out. So i stood there, reading an instruction sheet aloud. He listened to the heart for a minute. Then the lungs. Then took the pulse.
"what do i do now?"
"You say The Words!"
"What are The Words?"
"You say 'time of death'"
"Time of Death"
"'1901'"
"1901" And with that, the patient was formally dead. Only 1.5 hours after actually passing on. But then, life is strange like that!
I don't think I'll forget this- literally talking a doctor through someone's death. It seemed so silly, since the patient had obviously already passed on. We were the ones screwing around- they were at peace. If I were the patient, I would be giggling in heaven right about now. :-p
Thing is, I've seen dead people before-both in clinical and in the field. This time though, there was a difference- our MD was a brand-new intern. Didn't know the patient, since she was only admitted that morning. And, while well-meaning, he's a bit hesitant (I'm sure it will wear off). He had to certify death. He didn't know how. We had to walk him through it, and then I helped prepare the body for the morgue. The patient had had false teeth. The postmortem checklist specifies that you must replace them BEFORE sending the body to the morgue, lest rigor set in, and cause the face to be stuck without its teeth. I really REALLY didn't want to be the one to put the teeth back- after all, what if the patient rose as a zombie?!? WITH MY FINGERS IN THE MOUTH!!!!
I don't know why, but that really stuck with me. My patient could rise as a zombie, and us without a SINGLE machete on the floor!
It was only after we'd put the toe tags on, and the body IN the bag and zipped it shut that he realized he'd never done the formal LEGAL certification of death. So I went and unzipped the bag, exposing the body. He asked me not to leave the room, and help out. So i stood there, reading an instruction sheet aloud. He listened to the heart for a minute. Then the lungs. Then took the pulse.
"what do i do now?"
"You say The Words!"
"What are The Words?"
"You say 'time of death'"
"Time of Death"
"'1901'"
"1901" And with that, the patient was formally dead. Only 1.5 hours after actually passing on. But then, life is strange like that!
I don't think I'll forget this- literally talking a doctor through someone's death. It seemed so silly, since the patient had obviously already passed on. We were the ones screwing around- they were at peace. If I were the patient, I would be giggling in heaven right about now. :-p
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