Whipple Chaos

A Whipple (or pancratacoduodenectomy) is a rather nasty surgery. They take out a piece (of a variable size) of the pancreas, and they take out your duodenum. Then they stick the NEXT part of your intestines (the jejeunum) to your stomach sort of like they would in a gastric bypass. They also attach your bile duct in there somewhere. Needless to say, when you go around stapling different body parts together that wildly, there tend to be...problems. Recently I took care of a whipple (ok, several whipples) with a Problem. You see, post-op they gave her a barium swallow, to make sure all those staples were holding. They were! (yay!) but that was on Monday. And now it was Friday, and...wait...NO bowel movements since then? Like...NONE? Ok...are they NPO? No? Cue sounds of impending doom. I spent the next TWO DAYS (on a five patient assignment) trying to fix this. Using Any Means Necessary. By day 2 we had dropped an NG tube, and there just wasn't...any...peristalsis. Wanna know how I knew this? The daily X-rays were showing the barium. From monday. In the SAME PLACE. So i'm spending the whole time saying to the team "guys, the enemas, the laxatives, the suppositories? THEY ARENT WORKING. Youre going to have to help me out here". And the attending is like "nono, just MAKE IT HAPPEN". and i'm like "...HOW?!?" So They want a CT scan, because by day 3, his mental status is going wonky, and he's getting tachy, and his white count is going from 11 to 20 over MY SHIFT. But here's the thing. Barium Swallow barium is 100% dense. CT contrast is 2% dense. The barium in his belly is basically acting as a shield that renders his whole belly opaque. And WHY can't I just "get it out of there"? BECAUSE I CANNOT TURN PERISTALSIS ON WITH A SWITCH!!! So instead, when his white count was getting ridiculous, his GCS had dropped from 15 to 13, and his vitals started to go off, we ran him over to the ICU. Maybe they'll have better luck explaining that i do not have a magic peristalsis wand. And they might want to fix that infection :-p

New Students

Someone has decided that, since I've been at Frozen Northlands Regional for over a year, i can be trusted with shiny new nursing students. Well I'm not sure what it says about the REST of the nurses on our floor, but apparently they like working with me. This might be because my stock answer isn't "go away" it's "look it up, tell me what you THINK is causing him to be that odd shade of yellow, and we'll talk". But I dont know what this particular school is teaching them. Cause DAMN. First off, when I was at Very Catholic Nursing School, we were taught that YOU. DO. NOT. SIT. DOWN. not unless ALL the nurses are seated, AND there are seats left over. Because if your nurse isn't sitting, YOU SHOULD BE HELPING- not just on your patient either! How about checking if all the beds are made? Everyone is washed up? Anyone needing ambulation? I know these are all students in their FIRST med-surg clinical, so they're not allowed to do a lot of things without me or the instructor, but ALL OF THOSE THEY CAN DO. So when they leave at the end of their clinical day, and TWO of my patients havent had their beds changed? or been walked? PLEASE! THERE WERE TWO STUDENTS!!! I mean, I'll get to it when I can, but I was dealing with the FOUR ENEMAS I had to give to the wildly unstable post-Whipple in one room, whose bowels havent moved in a week, and who was becoming progressively less coherent...but that's its own post. Suffice it to say, he was practically a one-to-one patient, on a five patient assignment.

Racism

Well DAMN! Ive been woefully neglectful posting lately, due to a combination of us being 7 nurses *SEVEN* short on our floor, coupled with all sorts of random bull. So. I've been on the floor for over a year now, practicing All By Myself. Know what's been striking me lately, now that I have enough experience to look up and around me instead of STRAIGHT AHEAD TRYING DESPERATELY TO GET EVERYTHING DONE? There are a hell of a lot of racists here in the Frozen Northlands. Not my colleagues. They're pretty chill. We have nurses and docs from pretty much EVERYWHERE, since we're a Badass Teaching Hospital known for having some of the NICEST people in the universe working for us. It's the patients. We are a predominantly white area. REAAAAAALLY white. And a disturbing number of people get pissy when their nurse (or even their doc) isn't lily white as well. Case 1. A few weeks back, i had a patient go on at me for TEN MINUTES about how his night shift nurse (the fantastic Minh- seriously, this chick never misses a THING on assessment. She's a rockstar. I had her teach me about limb ischemia when i started, because she is SO FREAKING GOOD) "didn't smile enough, wasn't caring enough, and can't speak english- if she's in this country she should try to speak the language!" ...Minh speaks PERFECT english. She's university educated in two countries, and can do flawless medical translations in two languages (English AND Mandarin) and she's passably good in Cantonese. Not just SPEAKING THE LANGUAGE, but MEDICALLY LITERATE. Sure, she doesn't grin at her patients, but they're tucked in, with snacks, clean, cozy, warm blanketed, and they get checked for comfort HOURLY. With a five patient assignment. I asked the patient what he would LIKE in his care. He said "well girls like YOU- you know, local girls!" I was like "sir, i'm not from here. And that sounds a bit racist." Dead...stunned...silence. I learned this technique from my cousin-in-law Roberto. He's from Chile. He says the best way to deal with racists is to flat out tell them "youre being racist". People usually just blush, and try to ignore behavior like this, and then the jerks dont get called on bad habits. Case 2. One of our awesome new surgical interns, Olivia, is of chinese descent. She and another intern, Rajan (indian descent)were doing a dressing change, supervised by Erik, an Icelander...like...from Iceland. The patient called me into his room first (DIFFERENT PATIENT, SAME ATTITUDE): "who was that foreign doctor?" Me: "Dr Sigbjornnison? Oh he's a senior surgical resident. His name CAN be a little hard to understand when he speaks fast. " DPSA: "Nono! The colored one! the FOREIGNER! I need to know if he's any good- i mean, did he go to a REAL medical school? Here?" Me: "Dr Singh is from New Jersey, sir, and I believe he went to Syracuse" DPSA: "and the little oriental girl?" (said with a dismissive sneer) Me: "Dr Lee is from California. And she went to Princeton and Columbia. All of your doctors are incredibly well trained. If you have any concerns about their MEDICAL training, you can always ask your attending physician. Otherwise, please just let them do their jobs" As if these totally awesome people don't have enough crap to deal with as nurses and surgical interns...Its up to ALL of us not to let them suffer silently. If you hear someone making racist remarks about a colleague, CALL THEM ON IT. Politely, but firmly. After all- this is a team sport.

A Simple "Thank You"

I had 5 very difficult male patients today: A. was a mildly confused ETOHer with acute pulmonary edema who desatted and got dizzy...and bradied down to the 30s...every time he tried to walk...which was often. B. was a vigorous 50something year old man whose little toes we had amputated...on both feet. He could manage to carry a cup of coffee AND a bottle of water in his bathrobe pockets without spilling anything. He's married to a nurse, you see, and wouldn't want to bother US for things "he can manage himself"...even at the risk of coffee burns C. was a man who was just...needy. His feet itched. a lot. he wanted them rubbed. Then massaged with lotion. then benedryl. then more lotion. Heaven forbid he should do these things...himself! nono! the NURSE should do these things for him! D. was the delightful 90 year old with soft blood pressures and a penchant for telling world war 2 tales...i could have listened to him ALL day...except that i had to somehow figure out how to get his massive seroma drained without tanking his vitals...which would be untenable...as he is so damn NICE! E...ah E...he didn't seem to like us much, me and my Lovely Assistant K...he grumbled, complained, didn't like us much. And then he surpassed all our expectations. He passed his PT eval, swallow study...everything. And then on his way out the door he grabbed my hand. "I want to tell you, before I forget". He said, like an old movie star- "I've been HORRIBLE to you all- short tempered, cranky, unkind...but I want you to know- you've been WONDERFUL to me!!! You treated me like you expected nothing LESS than my full recovery, and that made me work harder. You never took it out on me when i was mean to you. I wanted you to know, I am so very grateful to ALL of you- nurses and aides who took care of me. Please tell them for me" And then he left. But...that's why I do my job...for people like him...and for the people who never manage to tell me that what i do matters...but really? People like him make my day... Even though two hours later I got puked on and yelled at :-p

Clinic Admits

330 PM, and I've just discharged a patient. JUST discharged, as in I'm still stripping the room, and housekeeping hasn't made it up to clean yet. Phone rings.

Me: "Surgical Floor X, this is Alpine, can I help you?"
Ennui, RN: "Hi, this is Ennui, over in Vasc surgery clinic. I'm sending a patient. Can you take report?"
Me: "The room isn't clean yet. I just want to make that VERY CLEAR...but yes, I suppose I can take report."
Ennui, RN: "pt is a large-ish gentleman with an extensive vascular history. he has an infection. Needs IV antibiotics. Can I send him?"
Me: "wait a minute! what's the history?"
Ennui: "its in the chart"
Me: "indulge me?"
Ennui: "it's not in front of me. look it up when he gets there."
Me: "allergies?"
Ennui: "they're in the chart!"
Me (getting REALLY fed up): "Fine. Okay. Mental status? peripheral pulses? WHERE is the wound? Bowel sounds?"
Ennui: "didn't look at the leg...didn't listen to the lungs...didn't get bowel sounds...you can check the pulses, right?"
Me: "um...okaaaay"

What i was THINKING: "youre a NURSE??? What do you guys DO over there if you dont look at the wound, or do ANY assessment? You dont know this guys allergies? or history??? WHY ARE YOU CALLING TO GIVE ME REPORT IF YOU CANNOT TELL ME ABOUT THE PATIENT???"

I hear don't have to work nights, weekends, OR holidays...must be nice...

The Fifth Vital Sign

Pain is not the 5th vital sign. I know this might be an extremely contentious statement, but it's NOT THE FIFTH VITAL SIGN.

Here's why:

Signs are those things that are objectively observable and measureable. The definition of pain as "whatever the patient says it is, whenever they say they have it" is in direct opposition to this. If "i have 9/10 pain" doesn't mean the same thing to everyone, then it's NOT A SIGN. Blood pressure, respiratory rate, heart rate, temperature, and pulse oximetery are all SIGNS. If I take your blood pressure, with decent technique, and another clinician does the same, the results will be just about the same. Our evaluation of your PAIN however may differ wildly.

This is not to say that pain isn't an important thing to assess, or that it's invalid. it's just NOT A SIGN, and to call it one is, in my opinion, to devalue it, by putting it in the wrong classification.

Surge

We have a bed problem at work. The problem is that we don't have enough beds. Specifically critical care, and medicine beds. this results in having medicine patients on surgical floors. And that means sub-standard care for EVERYONE. Why? because all we do, day in and day out, most of the time, is SURGICAL care. We just dont SEE all that much of the pure medicine stuff. Or Neuro stuff, for that matter. I mean, we see it as a co-morbidity with your liver cancer, or your lung cancer, or your vascular disease...but most of the time we expect that you got cut open, and that that's why youre here.

The pure medicine patients also tend to be more likely to have EXTREME morbid obesity. Two of the patients i worked with last week were over 500lbs. Just lifting a LEG on someone that big puts you at risk for serious injury. Yes, we have "assistive devices" but...they're seldom where you want them to be, when you need them. That being said? CEILING LIFTS ARE THE BEST THING EVER!!!

Push a button, and your patient rises gently into the air...its beautiful...*tear*

Delusions of Grandeur

Last week my floor managed the impossible: We Discharged Super Sketchy Dood. After 2 admissions, totaling about 4 months in the hospital. After groping, pinching, throwing things at, and essentially sexually harassing EVERY NURSE UNDER 35...ON TWO FLOORS...and a decent proportion of the female medical residents and interns.

Super Sketchy Dood's troubles began quite a bit ago, when he made a serious mistake: he got on his dirtbike and went for an EXTREMELY drunk and high drive around his homemade off-road track. Somewhere in there he...um...tipped over. Since he was drunk, high, and of questionable intelligence, he picked himself up and went inside, not wanting to have the cops called on him. The next morning (okay, afternoon...no way he was up by noon) he woke up, discovered that his leg hurt like hell, and went to his local ER.

They sent him to us, clearly sensing Impending Doom. We saved his leg from the compartment syndrome he'd gotten. We wound vacced him, and then were promptly forced to drug him to his eyeballs after he bit a nurse. Then, crying and sobbing that "MY LIFE IS RUIIIIINNNED!!!" he ripped off the vac. And the graft. And lost the leg.

At this point, biting a nurse aside, we were all feeling pretty sorry for him. That lasted about...2 days.

To me personally, over the last few months, he: grabbed parts of my anatomy i prefer to remain un-grabbed, called me an "effing b*tch", tried to kiss me, and CHASED ME AROUND THE FLOOR in his wheelchair, yelling that it was "unfair I wouldn't date him just because he didn't have a leg". Awesome LNA (she takes no attitude from nobody), sick of being groped, wheeled around from where we were perched on the nursing station (out of pinching and groping range):

"Sir, it's not the leg. It's the pinching and the groping, and the inappropriate language, and that fact that you're a TERRIBLE PERSON. Know the guy in the next room? who's 80? and has gangrene? WE WOULD DATE HIM BEFORE YOU. Why? BECAUSE HE IS A GENTLEMAN."

When we watched the ambulance pull away, to take him to rehab, we went and got a cake for the resident who managed to get him to leave. And we didn't give him any.

Pain Management Skillz

Something every nurse deals with on a regular basis is our own pain at work. Since many MANY of us are female, a good proportion of us gets cramps every month, ranging in severity from "meh" to "OH GOD WHY IS THIS HAPPENING TO MEEEEE???!!!"
Since this is every month, it's not like you can take work off. Ergo, especially on a busy surgical floor, you can be treating all sorts of people in pain while you, yourself, are in pain. This can lead to issues, and a good deal of frustration. For example:

the person whose surgery was 2 months ago, re-admitted for high ostomy output, demanding narcs and REFUSING to walk "all the way to the kitchen" (a whopping 40 feet) to get their own juice. Because "i have cramps, and it HURTS". You get them their juice, and try REALLY REALLY hard not to say "CRAMPS??? I HAVE THOSE, AND HAVE NOT GOTTEN TO SIT DOWN ALL DAY! GET YOUR OWN DAMN JUICE!"

The narcotics werent a bad idea, since the point was to reduce ostomy output, but narcotics for CRAMPS??? eek! try a heat pack, like the one i just made you, that i wished i could make for myself, and curl up with the juice and the nice hot tea i got for you, and watch a movie. One of us should, and apparently it isn't going to be me! :-p

Coping Skills

Sorry I've been gone for a while, but I'm back now, with a HUGE backlog of posts to write *gulp*

Yesterday the Man-Friend and I were going to search and rescue training. He had agreed that we'd give a ride to a car-less undergrad. Fair enough. We had to collect said Undergrad at Local Pretentious Coffee Shop. At 7am. On a Saturday.

Now, I am not a morning person. I survive my first hour or so of consciousness by drinking caffeinated beverages, not talking and NOT MAKING DECISIONS.

Walk into Pretentious Coffee Shop. Man-Friend capably orders his coffee. Pretentious Coffee Person asks me "and you? what would you like?"

Easy question, right?

Me: Coffee please! Medium!

Pretentious Coffee Person (PCP): Yes, but what kind? We have 32 varieties of coffee, ranging from Columbian to Kenyan, or flavored coffees, or mochas...

Me: ...one that has coffee???

PCP: miss, that's all of them

Me: I DONT KNOW!!!! JUST...COFFEE!!!

Man-Friend, clearly trying not to giggle at this point, stepped in, and ordered something for me. Honestly, before my first cup of caffeine, i dont KNOW the difference between coffees!

Man-Friend: sometimes i wonder how you make life and death decisions at work...

Me: WITH COFFEE, DAMMIT!