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: " 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're right...if this is a result of his Other Medical Problems, this could be something where he's going to need help..."
Me: " more milkshake then???"


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" 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

Wednesday, August 10, 2011

Hiking Safety (Revised and Edited from Last Year)

Last year I posted on Hiking Safely, and after posting, I spent a month and a half working in the White Mountains with my brother as crew in a mountaintop hostel dealing with LOTS of small emergencies, (plus a few big ones) many of them brought on by simple lack of preparedness. This has applied even MORE to my Wilderness Search and Rescue work. It's dangerous out there, people! I don't just mean the bears (BEARS!) moose, rock slides, etc. I'm talking about darkness, cool temps, drizzle, all the things you don't think of when you think "hazards".

1. Pack an Emergency Bivy. Emergency blankets suck. I've used them on car accident victims, and they blow off in even a light breeze. Invest in a "bivy sack" for emergencies. They're under 20 bucks, and TOTALLY worth it. It's basically a metallic sleeping bag-style sack that's orange with reflective stripes. If you were to be caught out or hurt you could climb in WITH all your gear, and survive the night, or wait for rescue. REALLY WORTH IT.

2. LOOK AT THE MAP BEFORE YOU GO. The main reason people call for rescue in MY favorite mountains (the Whites) is that they overestimate their abilities, and get "exhausted" before they make it back to the trailhead. If you've never done more than a mile or two, DON'T plan on going THREE miles to the pretty waterfall without remembering that it's ALSO three miles BACK. If you DO call for rescue, (and can GET a cell signal) it could be some hours before people can get to you. Rescuers are volunteer, and a crew may have to get out of work, pack their gear, and hike in from quite a distance, depending on where you are. Therefore, MAKE SURE YOU CAN SPEND A NIGHT OUTSIDE. If you're not critically hurt (fell off a rock wall climbing, stomped on by a moose, fell in a stream and broke your leg, etc) you should be prepared to spend a solid night outside before you could be rescued. If simple exhaustion is your problem, think about this- IF you could wait overnight, would you THEN have enough energy to hike out? If this is the case, DO IT.

3. TAKE THAT MAP WITH YOU- this will sometimes be ignored (even by me, and ESPECIALLY by my brother), but if you don't REALLY know the territory, have memorized every trail turning and its approximate distance, and feel comfortable getting yourself back out of that area WITHOUT assistance, BRING THE DRATTED MAP!!! Sometimes a trail has a BUNCH of junctions, and without a map its really easy to get turned around. While we're on the subject, LEARN HOW TO READ A TOPOGRAPHIC "topo" MAP!!!!! Those little lines indicate ELEVATION, and are in increments. Someone who can read a topo map is able to summon a mental image of the landscape, simply by looking at those lines, to identify ravines, waterways, ridges, etc. This helps if you get off-trail, and need to know where you are.

4. has a good list of hiking essentials, but my top gear list would be the following:
NON COTTON clothing (cotton does not insulate when wet, and is heavy)- shorts and teeshirt
-raincoat and pants (dont need to be expensive, but need to keep water out)
-fleece jacket of some sort (the cheap ones work fine)
-iodine tablets (in case you have to be out there a while, to purify water)
-headlamp (seriously, dozens of people every year need rescue because "it got dark out"...BRING A LIGHT! Flashlights tend to be heavier, and you need to hold them, which can screw up your balance. Headlamps can be gotten CHEAP, and are worth it. I carry TWO.
-hat and gloves
-plenty of water

that's the minimum. hike in peace, and enjoy the outdoors!!!

Addendum: I carry a bit more than this, just based on my personal experiences-
A. I carry a very light first aid kit, even when I'm not on a rescue, with benedryl tabs, an epi pen, advil, immodium, pepto, a few bandaids, steri strips, and purell. This is because i can improvise most dressings with clothing, but it's internal complaints that will prevent your walking out of the wilderness. Pain meds, and ESPECIALLY stomach/intestinal meds, will give you the wherewithal to get yourself out.
B. In cooler seasons I carry a softshell, and wear softshell pants. Softshell fabric is water resistant (very) but super light and breathable. It's not necessarily cheap (unless, like me, you religiously keep track of clearance deals), but it's worth its weight in gold. You will be dry, not sweaty, warm (but not hot), and insanely comfortable, because most of these fabrics stretch nicely.
C. WOOL. This is my latest revelation. The new technical marino wools (Smartwool, Ibex, Icebreaker, etc) are, quite simply, the Best Things Ever. They do not stink, even if you are a large man and wear the same shirt for a week. They do not get out of shape. They maintain insulation in driving rain, and you can wash them in the washing machine. I am a complete convert. i even wear wool camisoles or long sleeve shirts under my scrubs. i SLEEP in wool yoga pants in winter. It's not itchy, it's AMAZING- like silk, but durable. If you make one "expensive" clothing purchase for the outdoors, skip the fancy raincoat and go straight for the wool longjohns. Plus, lots of it look PRETTY, and I've gone on DATES wearing my wool shirts, and have gotten nothing but compliments.

Hi, I'm Alpine, and I'll be your Nurse Today!

I still gulp when I say that, because it takes that heartbeat to realize that I'm NOT the student, I'm The Nurse. It has MY name on the whiteboard in the patient's room, just above that of the LNA. I'm still like "woaaaah" when I see it, and half the time I want to erase it, and write in the name of my preceptor, because my name on that board MEANS SOMETHING. It means that I'm actually making some of my own decisions now, (not all, I mean, c'mon- I'm still on orientation) and I go into EVERY patient's room with the thought, deep in my head, that this could be the day I accidentally kill someone, or that someone crumps on me and I have no idea what to do.

Not to say that I wouldn't like to get in on a code one of these days, I just don't want it to be MY patient (again, it's not that I want bad things to happen to people. I don't. I just want to be there if/when they do...because there's nothing that gets my brain going faster than trying to save someone's life in a true emergency).

I have also realized that, by trying to take my dad's advice on Looking Professional, I can wind up looking EXTREMELY depressing- all (ALL) my scrubs (still so excited that I get to wear scrub tops) are either navy, ceil blue, light blue-green, or black. The bottoms are navy, grey, or black. My mother calls me her "little black raincloud", and one of the managers has started to as well. Much as I hate to admit it, this might be a time to get a purple or, dare i say it, PRINTED scrub top (one of those nice Moroccan prints, with solid edging...prints of THINGS make me look like I'm playing dress-up, or that I'm a 12 year old in footie pjs).

But I'm hanging in there. I actually snapped at a neuro-surgical resident yesterday though- I was doing a narc-count for the Pyxis- you know, the ones you have to do after you get a dose out- when he asked if I would pull up a patient's vital sign page in the new electronic record. I held up one finger, trying to maintain my count (seriously, there were something close to sixty pills to count, and i get distracted easily) but he simply didn't get it. He said "NOW if you don't mind, I'm Very Busy!". I kinda snapped- whirled around, told him that I was COUNTING, and had forgotten my number, and now he was going to have to wait while I did it All Over Again. I also pointed out that HE could access the ENTIRE medical record on the computer at his elbow.

After I finished counting, he admitted that he'd never taken the time to learn HOW to use the record. He ALWAYS asked the nurses to pull the page up for him. Somehow this bodes ill for his patients, I think.

Friday, August 5, 2011

I wish I were wrong

This morning I walked into Favorite Patient's room, after a day off. What I saw mildly alarmed me- surely his eyes didn't quite look like THAT on I pulled open all the shades in his twilit room, letting in the full sun. His eyes were...well...yellow. Ran LFTs. Total bili of 9. Yeah...the mets ARE in his liver, and they're hitting the bile ducts. I don't think his self-prognosis of "6 months to live" is going to work. I think he's got WEEKS.

He was angry with me for the rest of the day, since it wasn't "real" until I documented it. Apparently HE was hoping it was a trick of the light too, when he saw it yesterday, and never mentioned it to the nurse.

He still can't put weight on his left leg, because the spinal mets make it hurt too much. Radiation hasn't helped him, and it's been a week. I give it a 50/50 shot that he gets out of our hospital alive to make it to hospice in Florida...

I'm not an outwardly emotional person, but I had to work hard not to cry when I explained that he really WAS jaundiced.

Then I went home, and explained to Man-Friend (who is a whole NOTHER level of weirdness), and got a hug (did have to explain what Bili means)...but he did make it a bit better. He, at least, doesn't turn pale and get upset when I talk about work.

Wednesday, August 3, 2011

In Which it is the Small Things That Count

Just worked two 12.5s, back to back, with the last shift ending half an hour late because our relief nurse was late. Had a fascinating patient who kept desatting every 10 the point where i was literally hovering over her bed going "BREATHE...DEEPLY...NOW" and watching her sats drop lower, lower, lower. I bit my thumb and watched.

While I blush and stammer while trying to program a Patrol or Sigma pump, I KNOW how to treat a desatting patient. You give them oxygen. You give them O2, page their intern, and pray they stabilize. The thing is, the patient already has 2 PEs. We just don't know where the big problem lies- we scanned her legs, no clot...scanned her head, no clot. This means that the problem may lie in her pelvis. Her radio-opaque pelvis. That's like...deadly emboli waiting to happen.

And so I hovered...for HOURS. And then shift changed, and I went home.

And I just got a text saying "got stuck helping with a coworker's thesis...can I come over late and snuggle?"

Yes. Because snuggling is never EVER too late.

Monday, August 1, 2011

In Which Life is HARD

Worked my first two back-to-back 12s on the floor as a New Nurse. Woah. Surgical floors are INTENSE. We had two patients pre-AAA surgery (pressures at 100 systolic? sure sir, i can try to maintain wait...she's back up at 140...give metoprolol...recheck...ok, now she's back up...fuck)

At the same time, we in the Frozen Northlands were involved in a rather large search and rescue. As a result I am exhausted. And it wasn't a good outcome either way, though lord knows we tried...and we didn't miss the subject where we were looking, they were simply elsewhere.

On the bright side, I haven't screwed up yet.