Just how sick are you?

We have had our fair share of super sick patients recently. And this is not necessarily a good thing. In all of the cases, each patient waited too long to seek medical attention.

Patient 1; late 20s: presents to the ER with difficulty breathing, fever, chills. Pt is sent to ICU with RR in the 40s and with an insulin drip. Pt is alert, able to talk, but is very uncomfortable. Throughout the night, I keep a close eye on this patient because I had a really bad feeling in my gut. Sats say upper 90s but I tell the other nurse with me that I just don't believe it. White count is over 40. While working through the admission, I ask the other nurse to please see if she can get me a couple more IV sites. BP stable, but HR increasingly tachycardic, in the 120s. As the night progresses, RR goes up to the 50s, HR goes up to sustained 180s. Sats and BP bottom out in a flash. Pt is in respiratory arrest, and is subsequently intubated. This happens at shift change. Later that same evening, the patient goes asystole and is coded, but is brought back. And what is brought back is not the same person that I admitted. This newer version of the patient has gross neurological deficits. This patient, who was able to talk at admission, is now pretty much a vegetable. We were sure that they wouldn't make it. Now, a month and a half later, the patient remains in the hospital with a peg tube and will need long term care for the rest of their life.

Culprit? Strep pneumonia.
Patient waited 2 weeks before seeking medical care.
Did you realize that 30% of pneumococcal patients become septic and then 30% of those die?

Patient 2: Patient in their 80s, presents to the ER with fatigue, weakness, and cough for 1 wk. Pt is transferred to the ICU due to hypotension and tachycardia, but was admitted to the hospital with pneumonia. Upon arrival to my shift, I listen to lung sounds and all I hear is water. Everywhere. Pt is alert, but a little nauseous. Nailbeds are dusky. O2 @ 6L per nc. White count 1.0. History of CA, but not currently. + Blood cultures. No urine output. As the night progresses, pt is unable to sleep,but is alert and talking. I teach the patient how to use the yankauer to suction the secretions out so that they would not have to use tissues, which in turn, dry out the mouth. It almost seems that the patient is getting better? Which I know is not necessarily a good sign. The next night, the patient expires. I heard it on the radio.

Culprit? Strep pneumonia.
I recently read that when white counts are low, it is not necessarily speculative of cancer, but in fact can be due to an infectious process so widespread that the body isn't able to produce enough white cells to counter those being used to fight the infection.

Patient 3: Late 30s, presents to the ER with abdominal pain for 3 days. Yeah, a regular presentation, but after testing, the patient is rushed to surgery as this patient has a perforated ulcer. Comes to the ICU post op and on the vent. I didn't personally have this patient, but I assisted with the care for 3 nights of hell. BP won't stay up, has to be on dopamine and then an epi drip. Pt is in renal failure. Continues to be on 100% FiO2 on the vent because this patient cannot tolerate any type of weaning before the sats bottom out. Pt is now in multi-system organ failure and expires 2 nights after my last shift that week. Died of pulmonary edema.

Culprit? Septic from a perforated ulcer.
Sad case, really.

Patient 4: mid 70s, presents to the ER with abdominal pain for at least a week. Admitted to the floor and to see the GI doctor, who subsequently schedules surgery for the next morning. Arrives to the ICU on the vent, but doing well. Surgeon tells the family that this patient waited too long to seek care, that it was possible that this patient would not survive this. Pt has so much ischemic small bowel, that there is nothing left at this time to take out and put together. 2 days later, the surgeon goes back in for another ex lap, and finds pink bowel. Only has to remove 6 feet and is able to reconnect the remaining so that this patient does not even need an ileostomy. A week later, patient is able to move the floor, completely stable, and completely aware of how close they came to dying. This was truly some type of miracle. This patient attributed it to the praying done at church.

No culprit this time. This patient was lucky.

Needed a break.

Took a break from the internet for about the last two months as I have switched over to working nightshift. Just didn't have the motivation to post anything, or do much of anything on the computer at all except read emails. So anyways, am back now :)

FAST

There was a patient who fell at home. Admitted to telemetry for syncope, which is a usual type of admission. Up and about, talking to family, walking to the bathroom, usual activities. Around shift change out on the floor, the nurses call the rapid response team. Pt has had a significant neuro status change. The pt is reassessed and md called. Pt is transferred immediately to the ICU.

Upon arrival, we all go in the room to assist with the admission. Primary nurse is assessing while the other nurse and I get the patient hooked up, vs, etc. At this time, the patient is barely responsive, has significant left sided weakness, and is having difficulty with secretions. Prominent facial droop to the left side. BP is 200s/100s. HR tachycardic with bursts of svt and vtach. Full code. Nurse calls the md and tells him to get in here now. You see the pt was a prominent VIP around town and the admitting md knows the patient personally.

As soon as the doc arrives, we assist him in performing an elective intubation. Amiodarone is given which stops the vtach episodes. The patient is sent downstairs for a stat CT. Doc is on the phone with trauma center attempting to find placement so we could get this patient shipped out. Until the films are done.

There would be no shipping this patient anywhere. The patient had a fatal hemorrhage that displaced almost the entire right side of the brain, and the only thing keeping them alive at this time was the ventilator and medications. Posturing is evident. Seizing is evident. The spouse wants to wait for the all of the children to come in to say goodbye. And so we oblige their wishes. The next day, the patient finally passes 15 minutes after being taken off of life support.

Not all stroke outcomes are such as this. A couple of important details that aren't in the story: Admitting CT showed absolutely no sign of hemorrhage. Secondly, the patient was on Coumadin, which probably contributed to the massive size of the bleed.

It is important for us as medical personel to remember the quick assessment for a stroke: FAST.
F: Face
A: Arms
S: Speech
T: Time.

Never underestimate the significance of your neuro checks.

short update

Just wanted to add in real quick that my nights preceptor is completely and totally different. Makes for a much better learning experience. Now I know I haven't posted much lately, just haven't been terribly inspired. Am working on it though.

Preceptors

What is it that makes a person a good preceptor? What are things that they do that makes them, well, not so good?

Does the preceptor need to adapt to the orientee, or should the orientee adapt to the preceptor?

I would like some input from others, your experiences, so that I can sort through what went wrong with my day shift preceptor.

So how did your preceptor teach and treat you? What worked the best, what didn't work at all?

Thanks in advance. :)

Pity Party for One

The party is for me. Because I am pitiful. True. At least I feel pitiful.

The first six weeks of orientation have ended. Not necessarily on a good note. I would go into all of the sordid details, but it would be a book. Really. I just want to say that every person has their own breaking point. Mine was about 2 weeks ago.

Now it's time to reflect, rebuild, and grow. And hopefully my preceptor on night shift doesn't lose focus on teaching me about critical care. Sigh.

I think I will go watch some tv, and indulge in some escapism for awhile. And maybe eat the rest of that pint of Ben & Jerry's sitting up in my freezer, calling my name.

looooooong week

This week has been mentally and physically tough, thus is why I really haven't had the energy to post much at all.

Tomorrow is my last day to arise before the crack of dawn. Wednesday I start nights full time. Really I am excited. I am so not a morning person by any sort, and I think this is what has been my major problem the past few weeks, eh months. I suck at getting up early. I sleep through the alarm, 2 alarms! I can't sleep at night, at least not often, and hardly ever before midnight to 1 am, even if I am up with the roosters. I guess some people are just meant to work nights, even though it does make you crazy lol. Well, am already crazy, so no biggie there. :) Not to mention, I have no problem whatsoever sleeping in the daytime.


On a different note... what is it that makes the teenager's smile? hehe





Happy Birthday to my now 15 y/o child who says money makes him happy. Boy, doesn't he have a lot to learn? Am sure his bday $$ is already burning a hole in his pocket.


I am quite certain that he has already mentally spent that money.... and probably on something like this:




He is obsessed with shoes. Obsessed. I guess better with shoes, than with something worse!

annoying

i just wanted to say how annoying it is to have the neighbor hammering in his garage at 11 pm.
That is all.

Fave Xmas Present

Not mine. I haven't picked out my new digital cam yet... but my kids wanted to let me know that the best present they got this year for xmas is tickets to see:



You see, they idolize Lebron. So I got them tickets to an NBA game featuring the Cavaliers. My youngest son said if he got to shake Lebron's hand, he would never wash it again. I just smiled on the inside. Heck, my teenager even smiled. He never smiles. I am hoping it will be great fun! I prefer college ball myself, but I think that it is important for kids to experience things like this.

WHY?

obviously, a lot of questions begin with this simple statement. but what I really want to know is this: why must commenters leave a full account of their experiences on a blog in lieu of commenting on the post or to other comments that have been posted? the most common of these seems to happen when someone posts something about pain/pain medications, so instead of reading comments pertaining to the post itself, I am reading comments detailing full experiences in the er/surgery/hospital stay/personal experiences with certain medications. Not that I mind, I just want to know why people do this?

rumor has it...

a head honcho's relative was hospitalized and said head honcho asks assigned nurse about this patient to which the nurse replied, "i cannot tell you anything, it would be a hipaa violation." rumor has it, head honcho was not so pleased.

personally, i am happy that i was not the assigned nurse or even work on this unit. phew. not that the nurse did not give out the correct answer, of course this person said exactly what should have been said, but on the other hand, to piss off upper management is not the best thing to do, is it? surely, some mild, nonspecific information can be given to appease the query by the concerned family member? i dunno. hipaa is so grey, and yet, so black and white.
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there was a code the other night in which the ethics committee was called in. young male, 40s, with advanced liver failure from years of etoh abuse was dead upon arrival, but just not technically. rumor has it that he wanted to be a dnr, but the spouse was not having it. spouse loses her mind, starts hitting walls and acting out when things start looking bad, refusing to grant patient wishes for dnr status, demanding everything be done for him and then accuse the hospital of killing him? ethics committee arrives as coding commences. i suppose that a sat was unobtainable via the standard probe, so a nurse went out to get the portable pulse oximeter, and stated "could you hand me the pulse ox out of the drawer." note, this is in the middle of a full code, the whole nine yards. ethics committee member states " she didn't have to be so rude; she could have said please." (now seriously, can you imagine running a code in this manner: start cpr, please. thank you! could you please push the epi? thanks so much! ok, now let's please check for a pulse, if you find one, raise your hand! great guys! thank you thank you!) *rolls eyes* obviously, this member of the ethics committee has zero clinical experience. oh and by the way, for the spouse whom i have never met, i believe it was probably the years of etoh that killed your man. it's a tough reality to accept, and i for one, understand that even though people have stated you lost your mind, i am sure you were just in the denial/anger phase of grief. hopefully you have the intelligence to see the dangers of drinking in excess and yes, it really does kill you, eventually.
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not really a rumor, but in the news. i have read a lot of differing public opinions on a certain female celebrity, young mother of 2, we all know who she is. so many people believe she is being a spoiled brat, and have said some truly vile things about her and her actions. obviously, this young celeb is suffering terribly, the difference is that there are cameras on her every minute of every day, and we the public are seeing first hand an evolving mental illness, in my opinion. the reactions that i have read are the reason why mental illness has such a stigma around it. people truly cannot seem to understand that rational people do not act this way. rational people are in control of their lives. whether her problems are chemical or physiological in nature, it does not matter. we will be reading her obituary and grief stricken fans will be holding candlelight vigils if something is not done soon. the real losers in this situation are the children. they will forever have to hear about "how their mommy lost her mind." real people suffer this truth every single day. not just celebrities. i think the public needs more exposure to mental illness, to see how it really is. and not the movie made up stuff. real psychotic breaks. maybe then all of this wouldn't be so funny. because it is not funny anymore. they have a tv show intervention for drug users, how about a tv show that is an intervention for our psych patients? they can call it committed or whatever.