Wednesday, September 30, 2009


The ICU today was FANTASTIC! We were all basically thrown at the unit, and with a 10 bed unit, 8 of us, plus ANOTHER student from another school, pretty much all the nurses had students to do the heavy lifting, which they seemed to really enjoy. MY nurse was totally AWESOME. Our patient was really honestly an ICU patient- she was really truly unstable, with resps in the 30s, HR in the 120s-140s, BP all over the place.
And end-stage MS. Really tragic. She was REALLY young for it- in her 30s, and her "admitting complaint" was MASSIVE pneumonia. She realised upon admission that she was probably terminal, and made herself a DNI...but NOT a DNR. This put us all in a bit of a quandry- we needed to suction her, we could hear the ronchi from the nursing station- but she would fight tooth and nail against the NG suctioning, which would bring up little bits of THICK mucus, but it didn't feel as if we were doing much good. For REAL help, she would need something about the size of a garden hose, which would have to be put down her throat through her MOUTH, but she couldn't tolerate it. She would need to be tubed for us to reach her lungs, which we couldn't do. So...we did our best, rolled her side to side, restrained her arms by tucking them inside the covers (she would rip off her NRB mask in panic, which would make her de-sat into the 70s, even when I would HOLD it there, and remind her that she NEEDED the mask.) The hardest part was that she was mouthing "help! I cant breathe!"
But it was both challenging, and really DIFFERENT...I loved it.

Oh God the Crazy!!!

For the past week or so, my life has been MADE of crazy. On Monday I had a woman who really REALLY should have been allowed to be a DNR. Unfortunately for her, her family did not have the time to visit grandma, so she was a full code. And I spent the ENTIRE day running to her room as her vent alarmed, jumped into the Iso gown and gloves, and checked the vent, which inevitably was only alarming because of LOL's silent coughing and agonal resps. Of course, the nurse didn't go in ALL MORNING, and only spoke to me insofar as she had new orders for me- i did all her discharge work. Yeah. All of it, except for WRITING DOWN the progress note, which she had me dictate, so it would be in her handwriting. Not fun.
Yesterday was my BIRTHDAY!!! Except I had classes from 8-1, and then I went and got cake to bring down to the EMT building, because eating cake alone is sad, pathetic, and very VERY fattening...except there was an executive board meeting they forgot to tell me I sat outside from 2-530 and studied...and got quite chilled. Then had 20 minutes to bolt down some cake before running to my developmental psych class...then straight off to bed for clinicals this morning.
Today the CPU was actually CLOSED, due to low census, so we ALL went to the ICU, which was half CPU patients, half ICU...and that really should be it's own post...

Saturday, September 26, 2009

100th Post, EMS Overnight Shift

Last night at 6 I went onshift for the 18 hour overnight. Since it's parent's weekend at college, I was thinking SURELY it would be a quiet night. I mean...who would go out to get drunk with everyone's PARENTS there?

Well, as it turns out, quite a few idiots.

First call of the night was the only REAL call- anaphylaxis in progress. The poor guy was on his SECOND life threatening reaction of the day, having had one yesterday MORNING, and only been released from the ED about 6 hours before we got called out again. He still has no idea what he's allergic to, but my god I've never seen hives like that. He was really intelligent though, and had already taken a BUNCH of benedryl before we got there. I'm convinced that it's the only reason I didn't have to hit him with the Epi-Pen. I prefer NOT to do that to people who have just gotten their own Epi Pen prescriptions, because I don't want them scared if they need to inject themselves someday.

Third was a simple cooperative post-vomiting drunk who we promptly sent off to bed after a stable set of vitals.

Second and fourth were the "fun" ones. They were the ones who make you want to smack them a little bit- the drunks who were combative, verbally abusive, and whiny all at once. Number 2 was worse from the "whiny" and "combative" standpoints- engaging in a LOVELY combo of invading our personal spaces and trying to run away, while she sobbed loudly that "now she was gonna be in trouble and it was all our faults". Um...this was going to be her FOURTH write-up. Shes a freshman. That means an average of a write-up per week. In contrast, I didn't get written up AT ALL in FOUR YEARS of college, not counting THIS degree. That means not only does she drink more-or-less constantly, but she isn't very good at staying out of trouble.

Number 4 was actually not all THAT drunk. We were planning on releasing her into the custody of a sibling, but then she said the magic words "It doesn't matter what you do, i'm going to kill myself anyway". Whoop! That, combined with absolutely obvious alcohol intake equals a trip to the hospital. Sorry sweetie, saying "i dont consent! i'll sue you!" is NOT going to get you out of this one. Once you voice a wish to kill yourself, you become legally incompetent as far as we're concerned. Since you're drunk you CANNOT consent or deny treatment, and since you're voicing suicidal ideations we cannot release you to the custody of ANYBODY without a doc's evaluation.
Plus, you called me the c-word. Now I'm not sympathetic anymore. In addition, this being the FOURTH call of the night, it's 4 am and I havent SLEPT YET.

I understand depressed patients, and even suicidal ideations. I've been there myself...but I lose all my warm fuzzies when you start abusing me. Hell...i'm VOLUNTEERING here. I'm staying up ALL NIGHT WITHOUT PAY to make sure you're ok. The least you can do is NOT insult me.

And now...i'm exhausted.

Wednesday, September 23, 2009

I See JHACO People

Today JHACO descended upon Awful Hospital (aka Bobs Hospital)...and chaos did reign. The very first thing we were assigned to do (since we figured we had an hour or two before they got all the way up to our floor) was CLEAN UP THE UNIT. Now...I have no problems cleaning, but it was pretty damn clear that nobody gave a damn about making our lives any easier- leaving things for us to collect instead of picking up behind themselves. Once the unit looked pretty good, I was promptly yelled at by Overstressed Clinical Instructor for asking what the combination was to a cabinet, as I had found a PILE of unused saline flushes, and wanted to put them away properly. "DONT SAY 'they just locked the cabinet'! THEY'LL KNOW WE DONT LOCK THEM!!!!"

Look. I'm a student. I DONT know where everything is yet. I DONT have a password to the COMPUTER, much less the combinations to all the cabinets. So...I ask questions! Yelling at me that I'm not supposed to ask questions because the sheer fact that there IS a question reveals incompetence on the part of the unit is SO not my problem.

After the inevitable conflagration over ALL of us having "inadequate" charting (I wasn't DONE yet, I was IN THE ROOM, doing NURSING CARE on my PATIENT), she then continued to panic...and panic. It's not her unit. She doesn't even work there anymore, and hasn't in years, and yet she's going around putting up the JHACO mandated signage in the rooms instead of helping US. My school is paying her to teach US, not to help Bob's Hospital look good.

On the bright side, my pillow-fluffer patient was looking much better today, and actually managed to be cheerful, in spite of pissing me off by pressing THE CALL BELL for "a drink of water" despite said water being approximately 8 inches from his bed, in a cup, with a straw, and plenty of ice. He didn't want to take his arms out from under the covers to reach it...BUT HE HAD TO DO THAT TO REACH THE BELL!!!!

Headbanging on walls commenced. NLN CONFERENCE TOMORROW! HUZZAH!

Monday, September 21, 2009

Pillow Fluffing

Today we had TWO patients, and i was paired with a different partner. This was ok...we differ on a lot of points of opinion, (she thinks vaccines are scary and evil, I love them) but we work okay together. One patient was a lovely man with lung cancer, admitted for a cardizem drip for new onset A-fib. He and his wife were REALLY with it, asked great questions, took notes on everything the docs said, so that when the NEXT service came by the docs didn't have to go over the same things again and again.

Our other patient wasn't nearly as easy. He weighed at least 250-300 pounds, and was paralyzed from the waist down, according to him. He could, however, feel everything down to the tips of his toes, and i'm not sure how much was paralysis, and how much was deconditioning due to bedrest and pure LAZINESS. Now, I'm a student. I like to give my patients the benefit of the doubt, but this man had two working arms. I know this, because he had the remote control in one hand, and the telephone in the other, and he was holding the phone up to his ear PERFECTLY, and clicking channels...and yet he continually asked to be spoon-fed, and to have his juice held gently to his lips while he sipped.
My answer was simple "oh sir, we're trying to encourage self-care behaviors! Can you please do these range of motion exercises for me? No, I will not wipe your chin for you. Here's a tissue".

And then the call light started going off, while I was helping do the med-pass for my other patient, who needed a blood draw. WHY was the call light going off you might ask?

He wanted his pillow fluffed. And then another DIFFERENT pillow. And then THAT one needed to be fluffed. I understand that patients get lonely. I understand that human contact is important. I am not a candy striper, and taking advantage of the fact that, as a student I HAVE to RUN to answer call lights is just a dick move. No points awarded, sir!

PS- I DID fluff the pillow, btw...I'm not irresponsible! (That and my instructor already wants to kill and eat me)

Thursday, September 17, 2009


From the very first day of nursing school...the very first HOUR, actually, they tell you that you MUST be your patient's advocate- you are the ONLY THING BETWEEN YOUR PATIENT AND A MESSY DEMISE...or at the very least a hospital acquired infection, mental anguish, whatever.

And then, after this indoctrination, you're sent out, bright and shiny and optimistic, into a clinical setting. Where, at least at THIS clinical, you get chewed out if you ever dare to DO any patient advocacy. In this case, it was trying to get everyone to actually glove and gown before coming into the room with someone infected with ESBL...which is a NASTY little bug, version of E. coli...this is in addition to the standard MRSA. I just politely asked a doctor to please put on a gown over his lab coat (which i doubt he ever washes), and was told by my instructor that it was not my place to tell doctors what to do. MY place as a patient advocate is apparently to "Advocate By Setting A Good Example". are we training our nurses of the future if we start silencing them before they even graduate?

Wednesday, September 16, 2009


I fear the stopcock. Its one tiny bit of plastic, not much longer than a fingernail, and yet it's the bit responsible for keeping a patient's body fluids on the INSIDE of the body. If it's on a PEG tube, it keeps stomach fluids and gastric acid where they belong. If it's on an A-Line, well then it's holding back the flow of arterial blood.
We need to be able to zero an arterial line on a regular basis, to keep the pressure readings as accurate as possible. To do this, one needs to flip the stopcock so that it is OPEN to atmospheric air, but CLOSED to the patient. If, however, someone has turned OVER the stopcock system because they prefer it that way, and you dont check EXTREMELY open the stopcock to atmospheric air, and the patient's arterial blood comes spraying out all over the place. OOPS!!!

It would also be terribly TERRIBLY obvious to everyone concerned what had just happened. As nursing students we take a lot of mocking from hospital staff...I dont like to give them any help.

And this is why I fear the stopcock.

Monday, September 14, 2009

Poor LOL

My LOL from last week was due to be discharged that same day, and, indeed, she was. Back to the Sketchy Nursing Home. She was BACK to the unit this morning, however, once again Uroseptic, with abnormal ABGs. Apparently somebody messed with her vent settings, and her pH was something like 7.22. For those of you who don't know body pH yet, 7.22 is QUITE acidotic. Normal is 7.35-7.45, and you really don't have much leeway. Also, it looked as if nobody had really thoroughly bathed her during that time, as her skin was sloughing off in the most alarming way. It took me about half an hour to bathe her, which is impressive, considering she only has THREE limbs. I STILL didn't get HALF the dead skin off, and then my partner and I put an entire TUBE of aloe cream on her, to help with the itching.
Poor thing is quite heavy too, which makes turning her...tricky. The doctor says that she probably won't get better, and he would very much like to get an End Of Life plan for her, but that her family is dead set against a DNR of any kind, so she remains a Full Code.
Oh! and somebody else coded TWICE today, down the hall in the ICU. They remain alive-ish.
Kudos all 'round.

Saturday, September 12, 2009

EKG Interpretation

I have chosen to do EKG interpretation for my class presentation on Monday, along with Know Your Arrhythmias and Dysrrhythmias. This is because, for some unknown reason, I LOVE EKGs. I find reading EKGs to be both highly entertaining, and fun, especially when I can find even the smallest, most benign abnormality. Maybe this is because I'm new-ish at it, because as an EMT I knew basically two things about EKGs- "this is probably ok", and "OH MY GOD DEFIBRILLATE!". I appreciate the more subtle problems a bit better now, and will happily perch on any available surface to peer over somebody more qualified's shoulder to see new and interesting things.

Things I can now reliably identify:
V-Fib (if you CANT identify V-Fib, you're going to be in trouble)

Things I can Sometimes Identify:
Multifocal vs. Unifocal PVCs
Complete Heart Block

Things I Barely Understand At This Point:
Junctional ANYTHING
Various Types Of Heart Block
apparently none of these will be on the test, but i'm still going to look them up.

Wednesday, September 9, 2009

The Hard Part

They say (our all-knowing instructors) that the hardest part of nursing school is learning to THINK like a nurse- to assess WHILE performing all the other tasks set to you, and keep assessing at all times. To prioritize ALL of the things you have to do, and re-organize your priorities on the fly.

I am only just BARELY beginning to get a handle on this. When I'm on the ambulance, my priorities as an EMT-B are pretty straightforward- Airway, Breathing, Circulation, Get the patient to the hospital in a timely fashion. If all of these things are being accomplished, it's considered OK to actually just sit and look at the patient for a minute or two (40 minute transport times, yo). In nursing, (floor nursing at least) sometimes it seems as if you never FINISH doing ANYTHING, even while your basic priorities (Airway, Breathing, Circulation) remain the same. The difference is that there are innumerable other things to do, even for a rock-stable patient. Today was assessment during bathing and changing the patients bedlinens, interrupted several times to suction the patient's trach tube, and once to help save the patient in the other bed, followed by putting her tube feeding on hold, helping give meds, restarting the tube feeding, changing the patient's gown, changing all the wound dressings, MORE suctioning, several bedpans, et cetera. And I only had that ONE patient. AND I had a partner.
I think this is why I like the Emergency Department/Room so much- patients come and go, and I always feel more accomplished after doing a stint in the ED.

Maybe this will change as I gain my time management and mental listmaking skills...on the bright side, once again I made it through a clinical day WITHOUT killing anyone!

Full Code

Today was our first day with a patient of our own. We doubled up into pairs, since these patients are WAAAAY more complex than last semester. For example, most people last semester And breathe on their own.
Ms. E (SO not her real name) reminded me of my Grandmama- tiny, frail and old as rocks. She had what the docs called "alphabet soup"- you name it, she had it: Type 1 diabeetus, CHF, VDRF (vent-dependent resp. fail), COPD, previous history of CVA, seizure disorder, previous GI bleed, liver failure with jaundice, previous UTI, et cet. Oh and ALL FOR STAGES of pressure ulcer, on various parts of her body. Essentially, Ms. E was a mess. A MRSA-positive mess.
Still, she would grin at us as we assessed her, occasionally pointing imperiously to her trach for us to suction it. Then she'd wink. It was kind of a riot. She had just had one leg amputated above the knee, due to gangrene, and I'm pretty sure the other one is going to have to come off soon, if her nursing home doesnt learn how to treat bedsores.
Ms. E was a full code, due to her family wanting to give her "all the chances they could".
Her roommate was ALSO a full code, with agonal breathing on another vent. Both alarms were constantly going off as the two women shifted their heads, or coughed. That's why, since the curtains were pulled around the other bed, I didn't realize that the OTHER alarm was going off. Ms. E's roommate had pulled off her vent, satting in the 40s. I heard ANOTHER alarm go off, with a different tone (the BP alarm) and checked, and then suddenly the room was FULL of people.

"Quick! Grab the AMBU bag, and bag her!" A nurse yelled, so I grabbed the bag, attached it, and began bagging...against very little resistance. It took a minute for my instructor to run into the room...she blinked, and said "What's going on?" I explained that I didn't know that the vent alarm was going off, and so this all was probably my fault.
Everyone laughed. "It's not even your PATIENT, and it's your first day! How were you supposed to know which alarms were for which patient? Next time just run around and check ALL the patients in a room."

She stabilized, and all was well...but I will NEVER let that happen again.

Monday, September 7, 2009

Labor Day

So the apartment is finally in order! 3 hours of cleaning and organizing, another hour of getting Teh Interwebs installed, and i've got a place to live again! I am SO happy about it, because it means not inconveniencing someone when i come in late from classes.
The downside is that, as I live alone, and am not terribly close with most of my classmates, and the ones with whom I AM are working...I went this whole weekend mostly without talking at ALL.
I did make about 35 drug cards.

Some interesting nursing observations:
Cardiogenic shock is a very nasty thing to get- it basically means that your heart is no longer pumping in a fashion that lets it get blood into all the rest of your body...or at least not enough to get it into all the fiddling little places like does, noses, etc.

Ventilators: Bubbling in the FIRST chamber means an air leak- either its air coming down the pt.'s throat, through a hole in the lung tissue, and out the chest tube, or the tube has a hole. Check BOTH. If it's the lung, this should stop when the lung heals itself. DO NOT PULL ON THE TUBE.

Stopcocks: They are the DEVIL. Make sure they're closed the way you want them to be closed, or SOME nasty liquid is going to get all over the place. If you're LUCKY it'll only be the foul-smelling enteral nutrition junk. Couldn't they make it smell better? Please? (this one wasn't instructor was so busy telling us how to work a stopcock that she turned it the wrong way)

Codes: hospitals have so MANY kinds of codes now (Pink, Blue, Black, Grey, Red, Yellow, Orange, etc) that NO ONE knows what several of them mean...for instance, apparently orange means "patient surge" which i ASSUME means "we're getting swamped, call for more help for staffing" but COULD mean "omg, somebody got accidentally defibbed!" Code pink means "baby abduction". This means IN ALL SERIOUSNESS that they lock the hospital down, and you're supposed to ask people if you can check their purses for hidden babies. Seriously. Hidden babies. I think there's PROBABLY some leeway in saying "ma'am, i think your purse is too small to hide a baby in"...but you never know.

Wednesday, September 2, 2009

Effing Clinical

This hospital (Suburban Stupid Hospital With A Staffing Problem) sucks. There were THREE nurses for the whole ICU-stepdown unit. THREE. Which meant each nurse had 4-5 pts, at least half of whom were on a vent, or at LEAST totally immobile. That's totally unsafe. And the nurses were really angry when we showed up, because if they had KNOWN that we were going to be there, they wouldn't have done ANYTHING for the patients we were going to take. Except that we weren't doing patient care today, we were orienting to the unit.

They don't even have an aide, or an CNA. So...that's why they have us come there apparently. It's because they want to use us as free grunt work. That's NOT why we're there. I don't mind doing work. I like to pitch in, but we're there TO LEARN primarily. We are PAYING to be in nursing school, not to be unpaid aides doing tasks we learned how to do LAST YEAR. We're supposed to be learning NEW things, not just doing bedbaths. Assessments? Sure! Foleys? Glad to! Suctioning? Bring it on! Spending ALL MORNING cleaning patients, WITHOUT getting to do any of our new skills? NOT COOL.

And everything is either broken or absent.

And there are PLENTY of other clinical groups at ACTUAL TEACHING HOSPITALS, with staff who WANT to teach them, with doctors who show them things, with LEARNING to accomplish, which just makes this all feel dreadfully unfair.

Tuesday, September 1, 2009

Straws! Ventilated Straws!

Apartment is getting the cabinets ripped out and replaced today! This SHOULD fix the mold problem by eliminating all the damaged wood.

We're learning all about ventilators this week. They're scary. The idea that i could personally blow out somebody's lungs? very scary. Especially since half the settings appear to be specifically designed to prevent venous return, especially PEEP settings, which nonetheless sound exceptionally useful for somebody in severe resp. distress.

Besides, our professor is an old ER nurse, and LOVES her trauma. A few of us got in trouble for laughing at her photo of a guy with "BMW" impressed backwards into his chest from hitting the steering wheel.

what? i thought it was funny!