fish out of water

Got pulled briefly the other night to go "help" out in peds. It was a nightmare come true, I swear! I always do everything possible to get out of going to that unit. Sick little kids and babies are definitely not my cup of tea. Anyhow, they were getting 3 admits all at once, and since we were empty, guess who had to go on over? We had to move one patient to a different room, clean that room top to bottom, and then assist with the admissions.

Not to bad, but man did we ever work our tails off. We were praying for anyone to become critical in the ER. We prayed for an overhead code blue. Anything to get us out of peds. None it happened. So we were stuck until the peds nurse was caught up.

If it were me, I would have called in their unit manager and told her to get in there and help out. At least she knows what she is doing? Understands all that stuff that goes along with peds: special IV tubing, weights, etc and so on. No matter what people say, kids are not little adults.
Anyhow, it didn't take too awfully long to help them get caught up and we got the hell out of dodge, never to return we hope for a long long time. I found something else to do to occupy my time -- got to go start a few IV's out on the floor. Now that made me feel better!

Off to work I go. Thank god we got some patients again :)

CPR

This is why everyone needs to have a basic knowledge of CPR. I realize this is old news to many, but it does not matter that this story is old. What matters is that the people who were with this woman did not perform or did not know how to perform basic life saving skills. Ultimately, would it have saved her life? That is unknown, but it may have remarkably increased her chances of survival.

Happy Holidays!

Hope that the holidays find everyone safe, enjoying the time spent with your families. I also hope that you don't have to go to the stores tomorrow to return any gifts, surely the lines will be horribly long with loads of impatient post-Christmas shoppers, not to mention those returning gifts as well.

Lucky for me, I got CasH $$ so no need to return here :)
Have a wonderful holiday!

Accidents happen to Good people

Not that they don't happen to bad people, either. But in this case, it was a freak accident. Older gentleman, in his 70s, who lead a very active lifestyle and in really good health... strange I know for those that age right? lol. Anyhow, he was at home trimming the trees outside, when a branch that had been cut swung around the wrong way and knocked him off of the ladder onto the ground. About a 20 foot fall. Most people of this generation fall on rugs at home, or in the bathroom, or many other simpler ways. But this man fell from a good height and was taken to the hospital, where he was released with the diagnosis of a concussion.

Later on in the evening, at home, neuro status begins to change. He is slurring his words, barely able to talk, and is having weakness on one side of his body. Wife calls rescue, per instructions, and back to the hospital he goes. One thing inevitably leads to another, and patient is transferred to a higher level trauma center. Intubated. To neurosurgery stat.

A 4" section of the skull is removed to allow for the increased ICP. Body temp is lowered in hopes to preserve brain function. Obviously still intubated, with paralytics on board. Mannitol infusing. Family at bedside. Waiting for any change in condition, whether he makes it or not. It is touch and go for days.

One doctor says this is the best that it is going to get. All previous levels of function will be lost, and this patient will need to go to a nursing home for the rest of his life. Another doctor says that the other doctor is nuts, that there is always hope. ICP has come down now, and paralytics have been weaned. Patient remains intubated. He is able to follow some simple commands, and this gives the family all of the hope in the world. They refuse to believe that this is the best it will get. They have been researching and looking into rehab centers for him to go to soon.

This happened to a family member, and as one who does not live near where they live, we get a lot of second hand information from the wife and children and others who live nearer. As a nurse, it is killing me inside to not know what they might not be telling the family, or perhaps even what they are telling them that they do not understand. I wish I could be there to translate all of the medical information that has been thrust at them over the past week. But I am not able. All I can hope is that they are getting the information, the prognosis, and everything that they need to understand everything that is happening.

It is tough to be on the other side of the fence.

To Be Old and Alone, Drunk in the Cold

We have all heard this story before. Elderly person lives alone, something happens, no one finds them until finally someone goes to check on them.

According to family, this particular elderly patient lives alone. Spouse died about 7 years ago. Patient likes to drink... about a "6 pack a day" [which in medical terms usually means about a 12 pack a day or so]. Family brings over the booze. Aren't they swell? Can't bother to stay, but may as well get em drunk so they don't remember?

Meals on Wheels brings the food 3 days a week. Not sure if they just bring 1 meal, or what. Not important at this time. But this time, they showed up to find the patient unresponsive. Called rescue. Brought to ER.

Somehow, the patient got into a shut room in the house that has no heat. Yes, no heat. Body temp upon arrival at ER: 87.5; thus the unresponsiveness. Hard to say what exactly has happened or for how long the patient was in the room. Patient is not talking much at this point in time. Patient is sent to the unit.

FF to the next morning. I am lucky enough to say hi to my new regular body temp patient. Temp is now 98 degrees. Bair huggers do wonders, I say! But this is no longer the problem. Toes will be lost as they are getting darker as the day goes on. Started with just a couple of spots of purple on 2 toes and by the end of the shift, all the toes on both feet were purple and spreading to the balls of the feet. Fingers on both hands are purple down to the middle knuckle. Not a pretty picture, really. I figure this person who was once able to hold a can of beer in one hand and smoke a cigarette in the other will no longer be able to do it exactly as before. Talk about stolen quality of life of their own accord, or was it?

But this is not all of the problem. BNP is 2900. EF is 25%. Significant systemic edema to include JVD. Apneic for 30-45 seconds with compensatory respirations lasting 90 seconds. Did I mention full code? Flipping between a fib and sinus with a whole lot of frequent multifocal pvc's. Heart is getting just a tad bit irritated. Luckily BP is holding steady at around 100/70. HR 70s-80s. Mental status is caput. Barely alert, mostly restless and increasingly so. Came up with 2 PIV sites, one leaking and discontinued. The other is going good until the restlessness includes pulling off the gown and subsequently pulling out the IV. PLT are 60, so it takes awhile to stop the bleeding. A colleague and I then secure another site in each arm. One for fluids, one for 'just in case.' DT's are in the infancy stage.

Doc questions whether to start the nutrition or address the apnea. ABC's of course, and CPAP is started. Will this eventually matter though? Glucose on arrival was less than 25. The brain does not live without glucose. Is the mental status a reflection of hypoxia, low glucose, etoh withdrawal, or just a combination of the three?

All I can do is take care of each small thing as it presents and think big picture. Follow md orders. Hope like hell this patient doesn't suddenly crash unexpectedly. Will the apneic period suddenly overcome? Will we have to code this patient? Will they stop breathing or go into an unfavorable rhythm? My eyes are on the patient at all times.

Luckily, they survived to the end of my shift. For the most part, patient is stable but critical. It could go any direction at any time. Sometimes I hate the days when you just have to hope beyond all hope that they make until you leave.

But my biggest gripe out of all of this is WHY for god's sake do people not check on their elderly relatives/neighbors? Especially the ones that live alone. You know they live alone. Anything could happen at any time. Especially when you, as a family member, bring them alcohol every other day or so and then not check on them daily!! A simple phone call might suffice? If they don't answer.... Check on them! [Another case in point: eldery man lives alone, drinks. Falls on space heater but is so intoxicated, is unable to move off of the heater in time and suffers 2nd-3rd degree burns on both legs.]

Luckily this patient (above) had their meals delivered, but is this enough? It simply is not the responsibility of these volunteers to ensure the safety of another person. Sure, they do many things when they deliver food, but it is just not enough. It just makes me sad inside, because deep down I know this is not an isolated incident. It happens all of the time. ALL of the time. Sometimes it is difficult in this 'me' type society that we live in now to address all of these issues that really may or may not pertain to our own family or our lives. But something has to be done to address this problem. I wish I knew the answer as to how.

christmas shopping woes

Every year I think that I am going to get started early. Never happens. As of today, I have 0 things bought for Christmas, which is just over 1 week away. Why didn't I start earlier? Why? I do this every year. I know what happens. I guess I am just a procrastinator of the supreme kind.

Now, there is no way I am going to find any of the white/silver psp's. One child wants the white one and one wants the silver one. Now, I could potentially find the white one online, but the silver is to be found.... nowhere. So, can't get one for one child and not the other. I could order the nfl/nba jerseys they want from online, but now will they get here by Christmas? Doubt it. Sigh. (smacks self for waiting).

Not to mention, even going to the store for simple household items is a chore because of all the damn people out there shopping. Waiting in line for at least 30 minutes just to check out. I hate being in large crowds of people, especially the Christmas crowd. It sure does bring out the ugly in people. I've experienced it in the worst possible way.

Now I am going to go wallow in my misery a little more until I find something else to do. Like laundry. :)

welcome back

and yes, they will be admitted yet again. why? because they have one or more of the problems identified in this post. It is a never ending cycle of admissions until they inevitably meet Dr. G. or someone like her. Maybe even the embalmer will get them instead. Hard to say. But when they start coming in like this, you can be sure that one day soon, they just won't make it in to the hospital in time or that their family won't find them unresponsive in time. More possible even is that the disease process finally takes hold for good and won't let go until everything on the inside is ravished and gone. At least their suffering is over.


[ Yes there are really, truly sick people that have truly no reason for their disease. Yes, they too can come into the hospital over and over again. There are also people who are completely noncompliant and visit us far more often, giving them the status of "frequent flyer".]

chest pain, you said?

There once was a patient of a notorious past who came to the ER. CC is chest pain. Admit to telemetry for monitoring. Because of the chest pain complaint, orders include morphine 2 mg q4 hours, for chest pain. Enter nurse on duty. Asks patient if they are having any pain. Patient replies, not all the time, but my left arm hurts right now. Patient points to left forearm. Nurse asks the standard, on a scale of 0-10, how do you rate that pain? Patient replies with a 4. Nurse asks patient if they are having any chest pain at the moment. Patient states no. Nurse tells patient that they will get some Tylenol for the pain this time because when they go back to their 'home', they will not get morphine there. Patient receives tylenol. Nurse charts tylenol administration and documents the pain to arm and absence of chest pain.

Because pain with medication adminstration must be followed up, the nurse goes back into the patient's room to find out how effective the tylenol was. Patient states that it has not helped at all. Patient goes on to state that they said they were having chest pain the whole time that went from the heart all the way to the left arm. Nurse asks patient if they are having chest pain right now. Patient states that it is always present, that they have a 75% blockage of such and such artery. Patient states that when they were a patient at the awesome hospital, they got morphine every hour. Patient then begins to writhe around in the bed. Nurse has no choice but to go and get the morphine for the patient, who states that they are having chest pain. It is ordered. Has been more than 4 hours since the last administration. Patient is given the 2 mg morphine IV. Meanwhile, VS of T 98.7, HR 77, RR 20, BP 118/68.


Heart rhythm looks like this:

No ST elevation. Not even ST depression, as might be expected with ischemic pain. Patient is s/p cardiac cath x 8 weeks. MD is informed that patient is continuing to have chest pain. MD decides to ship patient out to hospital that performed the cath. Nurse hugs MD (not really, but she wanted to).

Fast forward two weeks.
Above patient arrives in er with seizures. Admitted to telemetry unit for observation. Has ordered tests, such as EEG, etc. Tests are negative. Neurologist tells patient that it is probable that they will be sent back 'home' today. Patient begins to have seizures again. This nurse was called in by 'friend watching over the patient' for a seizure that lasted for 15 seconds. Charge nurse then comes into room and patient begins 'seizing' episode again, in a tonic-clonic fashion involving mostly only the legs. Episode lasts 20 seconds. Immediately after episode, patient is awake and alert. No post-ictal confusion/sleepiness/nothing. Charge nurse calls neuro, gives ativan as ordered, and prepares to transfer patient to higher level facility per order. No further seizing episodes are noted after that point.

How come every time the patient was about to be sent back 'home', their problems suddenly got worse and also these problems required subsequent narcotic medications for relief? It is just frustrating to be manipulated by the system. Not saying that this patient did not actually have chest pain or that this patient did not actually have seizures. But I have yet to see a tonic-clonic seizure without some form of a post-ictal phase, even if it is just a short period of confusion. Maybe it happens? I don't know. The chest pain incident was just a ploy to get morphine. Yes, I believe that. But on the floor, we are required to treat to patient stated pain. Not too many chest pains, especially chronic as stated by this patient, have a beautifully normal sinus rhythm without any ectopy.

But there are 2 things that will get you sent to the hospital from this patient's 'home', and that would be chest pain and seizures. Sigh.

on the subject of emergencies

If your heart is showing any of the following on an ekg or a monitor.. you will receive immediate treatment.

These are life-threatening emergencies.

If you come in, and your leg looks like this:

There will be no waiting, I am sure of it. This will get you a lot of pain medication. And surgery.

If your chest xray looks like this, you won't be waiting long either.

Because you can't breathe. And you could even end up like the person in the previous post.

Ok, off rant now. Going to bed.

venting

Got sucked into the conundrum over here which makes me appreciate the type of patients I get to see. They don't walk, don't talk, and certainly get all the pain and amnesia medication they need for comfort.

If you end up like this... that was an emergency.

(btw, i have no idea who those people in the picture are).

Change of Shift..

.. is up at Emergiblog. Kim has a terrific edition up now for your reading pleasure.

ice. blech.

I love my brother. I do. But I am so glad not to be where he is right now. cold as hell. maybe have electricity. trees on your house. all is a nightmare that is the the midwest right now.

thank god i moved east. shoot, this would shut down the whole entire state here for like a month.

Clinicals

Clinicals were very stressful. It was like living in your own little world for about 2-3 days a week because you have all of this information to write down and put in your head for quick retrieval. It gave me horrible hand cramps from all the writing. In fact, our first year, we had to literally write out each drug card. Not typed, not pre-printed, but hand-written. It sucked, especially when I had a patient like patient 1 below. We prayed for the patients with only like 5 medications. But I also learned those medications very well because of it. In our second year, which is exampled below, we were allowed to type up the drug cards or use the pre-printed ones if we had them. Most of us didn’t, we just typed and printed them ourselves. One day, in our first year, I had a patient with anemia. Instructor wants me to write up ALL the anemias. I could have died. Do you know how many there are??? My hand cramped for like 3 days after that because we had to hand write those too. She was a tough one, but I respect her for it, even today. Ok, so you want to know what it was like in my clinical experience? Read below.
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Here is an example excerpt from my clinical experience:
Day 1: Attend lecture. Get patient assignment for the next day, which will be 2 patients.
Patient 1:
Diagnosis: Pneumonia. Patient history includes: HTN, DM, COPD, CHF, Hypothyroidism, AFib, GERD, CAD, CABG (2005), Bilateral Fem-Pop (2003, 2006), Smoker.
Med List: Protonix 40 mg, Atenolol 25 mg, Lisinopril 40 mg, Diovan 80 mg, Reglan 10 mg, Digoxin 0.125 mg, ASA 81 mg, Glucophage 1000 mg, Glucotrol 5 mg, Levothyroxine 100 mcg, Pravachol 20 mg, Lasix 20 mg, Aldactone 25 mg, Coumadin 2 mg, Novolog Sliding Scale, Lantus 40 units, Multivitamin, Zosyn 3.35 grams, Solumedrol 60 mg, Levaquin 500 mg, Xopenex/Atrovent nebs, Advair, Spiriva, Nitropaste ½ inch, Nicotine patch 21 mg, Ativan 0.25 mg, Gabapentin 600 mg, Hydrocodone 5/500 mg prn moderate to severe pain, Tylenol 650 mg prn mild pain, temp > 101.
Treatments: Blood sugar glucometers AC/HS, O2@3L per NC, Nebs q6 hours, Daily PT/INR, daily weight
Patient 2:
Diagnosis: Acute Pancreatitis. Patient history includes: GERD, ETOH abuse, Smoker, Cholecystectomy (2000), Appendectomy
Med List: Protonix drip 8 mg/hr, Demerol 50 mg, NS with MVI, Thiamine and Folic Acid to each liter @ 80 cc/hr, TPN @ 60 cc/hr, Lipids @ 10 cc/hr [total 150 cc/hr IVF], Nicotine patch 21 mg, Novolog Sliding Scale, Ativan 1 mg prn, Librium 50 mg prn.
Treatments: Blood sugar glucometers q 6 hours, Central line, Neuro checks q shift and prn, NGT to LIS with 30 cc irrigation q shift, bilateral soft wrist restraints

With assignments in hand, off to the facility (45 min away) for chart information to include: H&P, lab data, and any other information pertinent to the preparation tool and treatments scheduled. This takes 2 hours of writing stuff down and then 1 hour to drive home.
Get home. Make sure uniform is clean and ironed, if not , throw it in washer stat. Order pizza. Kids love you for ordering pizza. Send kids in other room to watch whatever they want. Kids love you more because they can watch Spongebob, Sportscenter, videos all evening as long as they get their homework done. Hole yourself up at computer or desk or kitchen table with all your Med-Surg, Drug, Lab, and Care Plan books. Write up the main medical diagnosis and one additional diagnosis for each patient – complete disease pathology plus anything else the book has in it so nothing is missed. Make a list of nursing diagnoses and care plan interventions expected for each patient. List all abnormal and pertinent normal laboratory data with explanations of each and why abnormal. Write or type up each medication listed on index cards to include: name, action, dose and route, contraindications, administration information, side effects, and nursing implications. Make sure kids are bathed and tucked in by 10 pm. You finally get to bed at 1 am.

Day 2: Alarm goes off at 4 am. Shower. Iron uniform if not already done. Pack bag with all needed nursing supplies, paperwork, and whatnots. Leave house by 5:15 am. Get to facility at 6:20 am and on the floor by 6:30 am for pre-conference. Discuss expectations of patients and their diagnoses. Get report from floor nurses. And off to the floor to begin your patient care. You are selected to give medications today on both patients. You have to do all patient care to include toileting, baths, linen changes, meals, etc. Also reviewing drug cards so that when quizzed by the instructor, you know these medications and why they are being given. You also have to find time to write your notes and assessments for review by the instructor. She would like to have these by 10 am. Continue throughout day until 3:30 pm when you break for post-conference. Leave facility by 4:30 pm. Get home by 5:45 pm. Plop on couch. Nap for 30 minutes until kids wake you up. Take youngest child to basketball practice. Bring sandwiches to eat on the way for dinner. Get home at 9 pm. Put uniform in washer again. Review paperwork for tomorrow and make any needed changes. Iron uniform tonight. All in bed by 11 pm.
Day 3: Alarm goes off at 4 am again. Get up at 4:30 and shower. Bag still packed from yesterday. Enjoy extra 15 minutes of coffee. Get to facility by 6:15 am and repeat yesterday all over again. Leave facility by 3:30 pm today as instructor will do post-conference in class tomorrow after the test. Get home and finish up clinical paperwork due tomorrow. Fix a real dinner tonight and get kids to help with clean up. Gather books and notes to study for test tomorrow. Get to bed by midnight.
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How the day went in the hospital depended largely on the patient. If you had a lot of extensive things going on, like above, it would be so hard to get everything done, but you did it. You knew your drugs. You knew their medical diagnoses in and out and could spew off tidbits of information at the drop of a hat. When the instructor asked you about the most obscure medication on the list and you didn’t know it, she would let you look it up and then tell her about it. One thing about clinical is that your fellow students were usually there to help if needed. And your instructor was always available. It was a team work environment. But I am so glad it is over :)

er trip

oldest son 'partially subluxated' his right shoulder joint this evening playing basketball. supposedly, he 'packed' a shot, felt the shoulder "slip out" and couldn't move his arm. so being the tough dude that he is [he is almost 15 now], he decided he would try to put it back in himself. then he calls me at work because he is in a lot of pain. oh yeah, he was in pain. but he got the joint pretty much back in place, so the er doc had very little manipulation to do. for me, the mom and not the nurse, this made me pretty happy because i would hate for him to have to endure anymore pain than he has to. although i have to say, that my son is pretty stoic when it comes to pain.

now he has to wear a sling for the rest of the week and got a note to get out of PE. he was ok with that, but he really wanted a slip to get out of homework for the week because he is right handed and said he won't be able to write. KIDS. :)

i wish i could say that this was one of the few er trips that we have had to do. well for my oldest, this is one of the few. he doesn't get hurt often. he has broken a toe before, and that is about it, really. oh yes, once he broke out in hives but never did figure out why.

my youngest has been to the er as a baby for influenza, hydrocele blocking urine output (several times) until that resolved, rolling down the stairs (hangs head -- who knew he would roll over to the stairs?? lol), falling down the stairs in the walker (yes, those warnings were heeded, and yes we had a gate, but oldest son left gate open!). One of the sounds you will never forget is the 'thump, thump, thump' of your child going down the stairs. Oh and he has had broken a finger too.

now, those are about the only reasons that they have been to the er. tonight a whole family with 5 kids running around the er waiting room, jumping, laughing, having fun, acting like normal wild toddlers all came in for an 'overdose'. Must have been benadryl with paroxysmal effects or something. they were seen before my child with the dislocated shoulder. good thing it wasn't serious on either accounts.

ok off for the night. gotta work in the morning. sigh.

where have i been?

I would love to say where I have been today, but it's a little to close to home. Just let me say that it involves something famous. :) once in a lifetime.

It was fantastic, really. But that is all I can say.

orientation

monday began my official orientation to the icu. started with the standard critical care classes, and orientation on the unit. not that i needed to be shown around much, after all, i did work in there as an extern for almost a year.



i just wanted to say how happy i am to get up in the mornings and show up for work. what a difference a change makes, especially a change to an area of your career that really pushes your buttons in the right way.

Continuing Education

Is it just me.. or shouldn't all states require nurses to keep current with the nursing practice? After short research, I have found that approximately only 30/50 states require the nurses to have a certain number of CEU's per required time period. In fact, I live in a state that does not require nurses to fulfill any of these requirements. Is that a good thing.. or a bad thing?

Sure, I think that we should all attempt to remain current after our graduation. But on the other hand, some of these continuing education units are damn expensive. Who wants to pay 30 bucks for each test that is sent in? I don't! I don't understand why it is so expensive, and just where does that money go? For instance, if your state requires 30 units/hours over a course of 3 years, and let's say for the sake of it, each article in your favorite journal that has these continuing education articles/tests for $29.95 each and worth 1.2 contact hours each.. that means that you will spend approximately: $750 to continue your education if you only go that route. That's a good little chunk of money for some people.

But, does this also mean that nurses who live in a state that requires these units are considered to be more 'up to date' than those who live in states that do not require these units? Does the responsibility then fall upon the facilities to keep nursing practice updated on new standards? Who is responsible for teaching these 'old' graduated nurses the new tricks of the trade? Graduate students? Staff education? I don't know! I guess if your state doesn't require these ceu's, then the responsible thing to do as a professional would be to subscribe to a journal or two or so to keep yourself updated. I know I do.