So report went something like this: This patient coded on the way in, but we revived them and now they are coming to you, on the vent, here are the settings... here are the labs... here is the monitor pattern... here are the meds they got down here.... here are the ivf's running... hx and allergies, family is with them, will bring them up in a few minutes. General report.. nothing special or out of the ordinary. Lots of sunshine, butterflies, and rainbows.
None of it prepared me for the patient they wheeled around the corner to come into the unit. They forgot to mention... the patient was... not even cyanotic, but more of a raspberry color. They didn't mention that... the patient was... having uncontrollable decerebrate muscle spasms. They forgot to mention that... the patient coded at home, over 40 min. away from the hospital. Oh and they forgot to mention that they actually coded the patient downstairs, called the code, and suddenly they got a rhythm back on the monitor and so they reconnected all life support because the family wanted everything done.
I yelled at my colleague when they wheeled the patient around the corner... "I didn't get report on that!" We laugh about that now, but it certainly was not funny at the time. The attending md was actually on the unit at the time, and this patient was one of his for a very long time, and he knew them very well. I have to say that he was speechless, and this certain md is never speechless. He just stood there and stared while we went to work on this neurologically devasted patient who was only kept alive by the ventilator.
Lesson learned. Beware the sunshine, butterflies, and rainbows... there is usually a storm brewing on the other side.
Showing posts with label nursing. Show all posts
Showing posts with label nursing. Show all posts
24 August 2009
23 August 2009
why?
just curious. why is there always a war between the er nurses and the inpatient nurses. i say inpatient because it really isn't limited to just the med-surg floors, but all the units. and the same goes for docs as well. attending docs always seem to have some sort of irritation related to the er/ed, whether it is with the docs or the nurses down there. i don't get it, personally.
23 March 2008
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.
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.
26 January 2008
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.
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.
16 January 2008
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. :)
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. :)
15 January 2008
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.
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.
06 January 2008
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.
--------------------
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.
-------------------
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.
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.
--------------------
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.
-------------------
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.
30 December 2007
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 :)
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 :)
22 December 2007
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.
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.
15 December 2007
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".]
14 December 2007
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.
There will be no waiting, I am sure of it. This will get you a lot of pain medication. And surgery.
These are life-threatening emergencies.
If you come in, and your leg looks like this:
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.
(btw, i have no idea who those people in the picture are).
If you end up like this... that was an emergency.
(btw, i have no idea who those people in the picture are).
13 December 2007
12 December 2007
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 :)
---------
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.
----------
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 :)
08 December 2007
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.
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.
05 December 2007
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.
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.
30 November 2007
change of shift
Change of Shift is up at Dr. Anonymous. I am pleased to be included in this week's edition.
Go on.. have a read :)
28 November 2007
Fatal
It was a simple case of clostridium difficile. Or so it was thought. But in reality, it was much, much worse. Thanksgiving day, the patient was in good spirits, mad as hell that there was no turkey to be ate or the day spent with the family. Mad as hell because the doctor said that the patient was full of stool and what was escaping was also positive for c. diff. The patient is on isolation. Lots of handwashing going on in the room by the staff, and family had been told to be sure to wash well too. But did they? They were reminded time and again, but can we monitor their every move? Anyhow, the patient was ordered a laxative to get the stool out overnight, which did not work until the next day. Samples sent to the lab continued to come back positive. Patient is in fairly good spirits, no distress, just upset because the laxative seems to have been working overtime now.
I did not have this patient the next few days. But fast forward 2 days, come into work and the patient is being transferred to ICU. WBC count suddenly up to 48. Is it an acute abdomen? I will never know. Once that patient was out of my care, then I had to worry about my new patients and their problems. But this patient just looked bad.
Fast forward 2 more days. WBC count suddenly up to 120. Pt dies. From C. diff resistant to antibiotics. Gone. Coincidentally, patient had a family member that had passed very recently from complications associated with the same disease. Hmph.
This is scary to me for several reasons. Did I wash my hands enough? I think so, god, I hope so! What about the family that had visited him on the holiday? Did they wash good enough when I wasn't there? Did the other nurses remind them to be diligent on handwashing? Did the other nurses wash good enough and often enough as well? Did the housekeepers clean the room good enough so that the next person doesn't get this disease?
I have had a lot of patients who have had C. diff. A lot. It can become so common at times (they seem to all be in the hospital at the same time) that it just becomes a nuisance. The constant stools. The smell. But never had anyone died from it here recently in the last few years anyhow. Now, I know I will learn from this. I am sorry this patient had to suffer that fate. Truly sorry. But now I will be super diligent in handwashing and all the precautions that come with this disease. Not that I wasn't following the guidelines before. Not that I didn't wash when entering and leaving the room. I always had on gloves, always. But the idea that somehow I may contact this highly trasmissible disease is just simply scary.
And for all the nurses out there, hopefully this will serve as a reminder of the true seriousness that C. diff can present. Be diligent.
I did not have this patient the next few days. But fast forward 2 days, come into work and the patient is being transferred to ICU. WBC count suddenly up to 48. Is it an acute abdomen? I will never know. Once that patient was out of my care, then I had to worry about my new patients and their problems. But this patient just looked bad.
Fast forward 2 more days. WBC count suddenly up to 120. Pt dies. From C. diff resistant to antibiotics. Gone. Coincidentally, patient had a family member that had passed very recently from complications associated with the same disease. Hmph.
This is scary to me for several reasons. Did I wash my hands enough? I think so, god, I hope so! What about the family that had visited him on the holiday? Did they wash good enough when I wasn't there? Did the other nurses remind them to be diligent on handwashing? Did the other nurses wash good enough and often enough as well? Did the housekeepers clean the room good enough so that the next person doesn't get this disease?
I have had a lot of patients who have had C. diff. A lot. It can become so common at times (they seem to all be in the hospital at the same time) that it just becomes a nuisance. The constant stools. The smell. But never had anyone died from it here recently in the last few years anyhow. Now, I know I will learn from this. I am sorry this patient had to suffer that fate. Truly sorry. But now I will be super diligent in handwashing and all the precautions that come with this disease. Not that I wasn't following the guidelines before. Not that I didn't wash when entering and leaving the room. I always had on gloves, always. But the idea that somehow I may contact this highly trasmissible disease is just simply scary.
And for all the nurses out there, hopefully this will serve as a reminder of the true seriousness that C. diff can present. Be diligent.
01 October 2007
Pt satisfaction rules, hospitals drool
Perhaps I am a bit jaded. I don’t know. I cannot for the life of me remembering being taught that the patient is always right. Now, I know that the “customer is always right” is an old adage passed down in customer service to keep those customers coming back. But when did patients suddenly begin to apply to these same standards? More often than not, the patient isn’t always right, otherwise why else are they in the hospital? Most don’t choose to be admitted, although granted there are those people out there who enjoy nothing more than being in the hospital.
I also understand making that stay in the hospital as pleasant as possible. Sick people are miserable and have the capability of making everyone else around them miserable as well. This misery feeds on the environment and trickles down to all levels of employees. But with the implement of all the muriad of information about patient satisfaction, I think it is high time that health care professionals take it back.
Being in the hospital is not about what you want, it is about what you need. Staying in the Hilton on vacation, for example, is what you want. But you don’t necessarily need it. The hospital is definitely not the Hilton. I mean, I would much rather be in the Hilton, but they probably are not going to be able to give me IVF. You will pay lots of money to stay in either, but only in the hospital do the employees also potentially pay for your stay, especially if you are on Medicare or Medicaid. Medicare or Medicaid certainly will not pay for your stay in the Hilton. Since many hospital earnings come primarily from these two sources, why can’t the health care professionals have a say in the care of the patients? Why do we have to bend over backward because the administration says so? Between all of the taxes paid from our paychecks, we probably send the government enough money to pay for that hospital visit. Why do we have to heed to the complaints of the people who didn’t get what they wanted out of their hospital stay?
Not all patients are like this. Many are very gracious about the care and information that we give them. But it is the few worm infested apples of the bunch who take the time to send in those surveys who ruin it for everyone. I don’t know if some people think that there is no need to send it in if you had exceptional care. It seems it is only the ones who had a “problem.” Is that really reflective of the care we provide as professionals? We are admonished like school children if we are not doing everything possible to ensure the stay in the hospital is not like the stay in the Hilton.
Some examples of things that will never be like the Hilton in the hospital:
* Your food will never taste like it does at the hotel. In fact, it won’t even taste like the food at home, let alone McDonald’s. But because of the food you eat in those places, you are in here with a blood sugar of 600. Please don’t be upset with us when your food tastes like cardboard. We are trying to make you better, and that food will most likely have very little sugar and salt. Sorry. And we will probably see you again in a few weeks because you didn’t follow the instructions that we left with you at discharge on your diet or medications.
* You will get woken up at all hours of the day and night. We do not have a wake up service. We need to monitor your vitals and all sorts of things, even at night. Unlike in the hotel, you are not here for rest and relaxation. You are here to get healthy, and if that means waking you up in the middle of the night because your heart rate suddenly dropped to 30, then we will do so. Sorry.
* You can call for room service in the hotel. They are happy to bring you whatever you want whenever they can. Shoot, you even tip them for their services. At the hospital, we cannot accept tips, even though we may bring you many things you want throughout your stay. But just because you want something, doesn’t mean you can have it. For instance, the person above with the cardboard tasting food, please don’t have your family bring you a bucket of chicken in. It will only make your stay that much longer because we will not be able to get your blood sugar under control.
* In the hospital, all rooms are pretty much created equal. [Unless you are in the OB ward, but that is different.] Please don’t complain about the furniture or comfort of the bed. In the hotel, you can have a nice, soft, pillowed mattress. But in the hospital, those types of things are difficult to clean and breed germs that we may even be unaware of. Yes, we understand that it is not like sleeping in your bed at home or at the hotel. There is nothing that we can do about that. Really.
Well, those are just a few things that I can think of anyhow. All I want is to take care of my patients in a safe environment. I cannot help it if the MD orders something not to the patient’s liking. Like actually getting out of the bed and sitting in the chair for a few minutes a day. Or being on a fluid restriction because your kidneys cannot handle it, and the extra fluid will send you into pulmonary edema, but every drop of fluid you can get your hands on you suck down in a blink. Gone are the days of patient responsibility. It has become an all hospital responsibility to ensure that everything is done to the patient’s satisfaction, regardless of outcome.
I also understand making that stay in the hospital as pleasant as possible. Sick people are miserable and have the capability of making everyone else around them miserable as well. This misery feeds on the environment and trickles down to all levels of employees. But with the implement of all the muriad of information about patient satisfaction, I think it is high time that health care professionals take it back.
Being in the hospital is not about what you want, it is about what you need. Staying in the Hilton on vacation, for example, is what you want. But you don’t necessarily need it. The hospital is definitely not the Hilton. I mean, I would much rather be in the Hilton, but they probably are not going to be able to give me IVF. You will pay lots of money to stay in either, but only in the hospital do the employees also potentially pay for your stay, especially if you are on Medicare or Medicaid. Medicare or Medicaid certainly will not pay for your stay in the Hilton. Since many hospital earnings come primarily from these two sources, why can’t the health care professionals have a say in the care of the patients? Why do we have to bend over backward because the administration says so? Between all of the taxes paid from our paychecks, we probably send the government enough money to pay for that hospital visit. Why do we have to heed to the complaints of the people who didn’t get what they wanted out of their hospital stay?
Not all patients are like this. Many are very gracious about the care and information that we give them. But it is the few worm infested apples of the bunch who take the time to send in those surveys who ruin it for everyone. I don’t know if some people think that there is no need to send it in if you had exceptional care. It seems it is only the ones who had a “problem.” Is that really reflective of the care we provide as professionals? We are admonished like school children if we are not doing everything possible to ensure the stay in the hospital is not like the stay in the Hilton.
Some examples of things that will never be like the Hilton in the hospital:
* Your food will never taste like it does at the hotel. In fact, it won’t even taste like the food at home, let alone McDonald’s. But because of the food you eat in those places, you are in here with a blood sugar of 600. Please don’t be upset with us when your food tastes like cardboard. We are trying to make you better, and that food will most likely have very little sugar and salt. Sorry. And we will probably see you again in a few weeks because you didn’t follow the instructions that we left with you at discharge on your diet or medications.
* You will get woken up at all hours of the day and night. We do not have a wake up service. We need to monitor your vitals and all sorts of things, even at night. Unlike in the hotel, you are not here for rest and relaxation. You are here to get healthy, and if that means waking you up in the middle of the night because your heart rate suddenly dropped to 30, then we will do so. Sorry.
* You can call for room service in the hotel. They are happy to bring you whatever you want whenever they can. Shoot, you even tip them for their services. At the hospital, we cannot accept tips, even though we may bring you many things you want throughout your stay. But just because you want something, doesn’t mean you can have it. For instance, the person above with the cardboard tasting food, please don’t have your family bring you a bucket of chicken in. It will only make your stay that much longer because we will not be able to get your blood sugar under control.
* In the hospital, all rooms are pretty much created equal. [Unless you are in the OB ward, but that is different.] Please don’t complain about the furniture or comfort of the bed. In the hotel, you can have a nice, soft, pillowed mattress. But in the hospital, those types of things are difficult to clean and breed germs that we may even be unaware of. Yes, we understand that it is not like sleeping in your bed at home or at the hotel. There is nothing that we can do about that. Really.
Well, those are just a few things that I can think of anyhow. All I want is to take care of my patients in a safe environment. I cannot help it if the MD orders something not to the patient’s liking. Like actually getting out of the bed and sitting in the chair for a few minutes a day. Or being on a fluid restriction because your kidneys cannot handle it, and the extra fluid will send you into pulmonary edema, but every drop of fluid you can get your hands on you suck down in a blink. Gone are the days of patient responsibility. It has become an all hospital responsibility to ensure that everything is done to the patient’s satisfaction, regardless of outcome.
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