5 minutes.

It was a relatively quiet night in the Unit. One had a possible PE and was alert and oriented. One was on a trach-vent and very well-behaved. One was in with sepsis s/p not going to dialysis with consistent low bp's, and had mrsa in the blood as well. So after a a fairly quiet evening thus far AND being able to to do actual nursing stuff rather than just simply cna stuff, I was quite enjoying myself. It was my first night in the Unit as well.

The nurse that I was assigned to and I worked on her assessments. We had to draw a blood culture from our trach pt d/t an elevated temp. So we were getting ready to put in the order and were discussing about how to draw blood from a cvc line - flush, draw and discard, then you draw the blood for keeps. This was just around 9pm. Then we hear a splash and the other nurse yells out to my charge nurse. We get up and look in the room of the sepsis pt to see blood everywhere. From the pt all the way to the edge of the door. So I run to get my "haz-mat" suit on (will explain in a minute)... my charge nurse immediately starts calling the doctor and getting meds and fluids for the room and calling the family. The pt only had a saline lock. I grab some pads to spread out over the floor to be able to walk into the room and immediately am told to suction while the other nurse gets the fluids ready to bolus wide open. As I am suctioning, the pt continues to vomit up copius amounts of blood. Clots the size of grapefruits come out. But the more I suction, the more the blood keeps on coming. The pt rolled the eyes, lurched forward, and then collapsed. And all we could do was continue to suction and stand there and watch that last final moment. The pt was a DNR. And it took exactly 5 minutes for them to bleed out and die.

However, there was no time to reflect. No time to call a code. There was no code; there was only 5 minutes. And in another 5 minutes, the family would be there. The experience was adrenalizing, and it would not end yet. We had to clean up that room and the patient so that the family did not see their beloved in such a shocking state. There wasn't time to think about it, we just started soaking up the blood from the floor, from the door, from the wall, from under the bed, from under the patient, from all over the front of the patient. Blood was absolutely everywhere. Yet as a team, we got it done. And the patient suffered no more. And the family did not have to suffer from the sight of all of the blood.

You always hear that a person can bleed out in 5 minutes, but it is just one of those facts that you store away in the back of the mind. You believe it, because they tell you it is so. Even though a small part of you wants to not really believe it, as it is such a short time. But that 5 minutes seemed like eternity. And until I saw it for myself, I was part skeptic. Now I believe completely.

As for the cause, it was a ruptured esophageal varices. Had there been time, we would have gotten the GI doc in there asap. Had there not have been a DNR, we might have had been able to try to do more to keep the pt alive. But we only had the 5 minutes of acute hemorrhage and it was over.

Now for some of the other side of the story... right before the "splash" the other nurse said that the pt said to "call 911" then it all began. Amazing how people just know, isn't it? But as we were scrambling around in our isolation gear to get this or that, especially for the clean up.. our alert and oriented patient was able to view the goings on. That door was shut, but there was no time to worry about blocking the line of sight. We had a medical emergency. So after it was all done... that other pt told me that they knew something bad must have happened as we were all running around in our haz-mat suits. It was actually posed more as a question, and I politely had to tell them that I was sorry, but I am unable to talk about that. 5 minutes later, they were calling for the chaplain to visit. Of course that pt was okay, no impending doom. Just fear. Fear that they too now knew just how quickly death can take a person.

Intubation...

Worked in the unit the past couple of nights, and for the most part, everything was very quiet. However, Wednesday night, the er admitted a pt under 40 y/o to PCU who had sats in the 60s down in the er, but by the time they got to the floor, they were sat-ing in the 90s. Then for some reason the sats dropped down to the 50s, even into the 40s, and they became completely unresponsive. So off to the unit they went, at almost shift change even. In the er, they pulled off 3000 cc of fluid with lasix. Anyhow, as soon as they came into the unit, anesthesia was called in to intubate. [For some reason, I believe I heard the er doc state that the pt had tracheal deviation to the left, but I didn't see the xray reports this evening past to know what had happened.] They were given a Diprovan drip to keep them sedated so they wouldn't fight the tubing. The BNP was only 309, which is elevated and thus the diagnosis of CHF. But at such a young age? The nurses speculated that they must have had HTN for quite some time for the heart to go into failure, or something else must be going on. I don't know how long they will be on the vent, but I felt so sad for them. The PCO2 levels were 118 and PO2 was 39 at the time of intubation. No doubt they were in critical condition. It was an interesting experience nonetheless, even if it happened too close to shift change. Emergencies are never planned for sure. I know some complained about them staying down in the er for so long, but when they came in, the main complaint was that the eyes were burning and that the feet were swollen. Not exactly a rush with those complaints. I truly believe that if they knew just exactly how bad they were, they would have gotten them straight to the unit without having to go through all of the waiting. I wish it were easier to educate people on the signs and symptoms that are serious and need attn right away. Ah well, now I am rambling.... after a long night of fairly quiet patients, I am just ready to go on to sleep.

Days off... RIP Jack

Finally finished 3 shifts in a row... not a whole lot of excitement within those days, and thank goodness mr. fists was gone. about the only thing that really happened was we had a confused little lady pull her foley out. ouch is all i can say about that. i know it must have hurt terribly, but on the other hand, thankful for the experience of getting to put it back in.

Today i start my second section of pharmacology. I am a little unsure about taking this class over the summer, mostly because it will be an intense 10 weeks with so much information to learn in not quite as much time. Will keep posted about how the class goes. I just know that I am tired and a little burned out on studying. I really need to stay focused toward my goal, no matter how difficult it is.

On a personal note.. my youngest son is "graduating" elementary school today. Fills me with a bit of sadness because he is my baby, and growing up so fast. Another sadness in my heart is the death of Jack Bristow. I loved Alias, and I loved his character.. and I hated it that they killed him in the end. Why couldn't he have just waited for help? Why? It was however a great end to a great show.. one that I truly hated to have to watch, because I knew that it was the end. Loved Syd and Vaughn finally on their beach in the middle of nowhere just living life... but with so many things coming to an end, yet the idea that some openings were left to be able to pursue if this show is ever revisited in the future. I will definitely have to rewatch all the dvds this summer, just to keep the whole series fresh. Anyhow.. I have to run to get ready for the ceremony... RIP Jack, you will be missed.

No Psych Meds?

This post stems from my experience at work the other night. I just wonder why it is when the psych patients get moved into the hospital that their psych meds do not tend to come with them or get ordered accordingly. There is a reason that they are on these meds! And when they do not have them, they can be restless and agitated and combative. Case in point, Mr. Fists. A rather non-eventful fellow, as long as you weren't touching him. He did not like to be touched, so getting his vitals and fbs was a bit of a problem. I did get him to lift up his arm for his bp, but as soon as I slid the cuff up and under, he changed his mind and flexed his arm catching my left arm at his elbow/bicep. Now he is a strong fella, but as I tried to get him to relax his arm, he decided he wanted to dig his fingers into my left wrist. Ugh. It broke the skin and caused a little bit of bleeding, nothing serious by any means. Unless of course you think about where his fingers had been before that and omg.. who knows what kind of crazy diseases this person might be carrying. I even had gloves on, but he dug through the end of it and still managed to get my skin. So, I quickly move to the sink and begin scrubbing my wrist with the warm water and soap. Heck we all know that the skin is our first line of defense, and so many infections are introduced by a break in that integrity. So I scrub. And try not to be upset, because he really doesn't know what he is doing.. or does he? And why didn't he have enough of his psych meds to calm him down so that we aren't having to be put in these types of situations. Anyhow, I ended up having to take a urine test - because the patient scratched me. I think that is ridiculous... I would much rather them test him to see what was growing under his nails rather than to test my urine. I have no worries; I am clean.. but is he? I have kept some antibiotic ointment on the site for a couple of days now, but one spot is still a little red. I have no doubt that I will be okay, but it is just the thought of bringing something home from the hospital that I just really do not want. I just hope that when I go back tomorrow night that he has been discharged. (please?) Although I am sure that our lovely Ms. Situation will still be there.

Ms. Situation was just admitted to the floor Tuesday night. Her responses were mostly limited to "yeah" and "uh-huh". To every question. Although she would answer "that would cause another situation" to some questions, such as when asked if there was any pain upon palpation of her abdomen. Not quite sure what her situations were, not sure I really wanted to know, but I did find it mildly humorous at the time. It can be difficult to ascertain specific responses from these type of patients, when they aren't exactly in their right mind, nor their left as it seems sometimes. This is when the training into non-verbal cues can become very handy. Even though the palpation may have caused a "situation", her grimace on her face told a larger tale. It was painful for her, perhaps she just didn't know how to express that in the right words. Well we shall see what happens when I go back tomorrow night :)

if you ever remember anything...

this wise words came from my preceptor at work... about blood transfusions. You have to understand first and foremost, she is quite an anal person. But anal is good in nursing, after all, we do have some responsibility and accountability for our actions and misactions. So anyhow, she is telling me, "if you ever remember anything about blood transfusions and blood warmers, always remember that the tube coming from the warmer goes directly into the iv site." Now I am not sure if the previous nurse that had set it up did it wrong, but by the look on her face and the disgust in her tone as she said this to me, but I assumed that it was indeed, set up wrong. I can already tell from my other experiences with blood, that it is not a fun task, not at all. I mean so many things can go wrong, and you have to continously monitor the pt's condition along with all of the other patients on the floor as well. Anyhow, keep those words in mind, tuck them away into a memory to be used later. I really would like to talk about the person who was receiving that blood, but first, I have to give another word of warning about blood transfusions. When running them as secondary piggyback, always make sure that the secondary is running and not the primary. This could cause big problems (like air in the filter!), especially since blood can only hang for a predetermined amount of time (4 hours). Tuck that information away for future use as well, I promise it will most likely come in handy.

Now about Mr. Transfusion... such a lovely fellow with a GI bleed who was absolutely zonked on pain meds the first part of the shift and all through the transfusions. Never even knew what was going on I believe. Working the floor like this, I don't usually get to go through the entire charts and learn everything about everything, but mostly just observe and assist when needed. So anyhow, halfway into the shift he springs to life. As I am entering the room for the second set of vitals, this man has his jeans on, and he is bound and determined that he is going to make a phone call, at 4:30 in the morning. No idea who he wanted to call, he just had to make a call. In fact, he demanded that someone wheel him downtown to make his call. As I tried to calm him down and assure him that he would be able to call from his room, he got a bit more agitated and things weren't looking so hot from my angle. So I went to the charge nurse and let her know about this patient and his demands and his agitation. From further assessment, it was pain driving his agitation (as well as an extensive etoh abuse history), so he received his pain meds which sent him back into the lovely pt he had been at the beginning of the shift. Sometimes I do find it intriguing when a pt throws you for a loop, this time however, I was just happy to have him sent to his own personal la-la land where I know he was much happier.

on my day off..

and i cannot sleep, of course. this is absolutely a side effect from working nights. You work nights therefore, you cannot sleep at night. Anyhow, I am just now getting started on my blog as you can read. I am about to enter into my last 2 semesters of nursing school and am so looking forward to this time next year when I will be done with this part of it forever (unless I decide to pursue my master's). I am currently working nights as a student nurse extern, in which I have seen and done so much more than I have ever thought of doing during my clinical experience. For that I must thank my POE (place of employment) for giving me the opportunity to stick tubes into people.. I love it! *grin* Unfortunately the rest of the reality is that those of us who have accepted this position are really not much more than glorified CNA's who are allowed to "do" things from time to time should the opportunity arise.

I have listed a few of my stories that I will share over the summer as well as adding in some new ones that I experience along the way. It is so difficult to find a way to share some of the stuff that we experience and see, as most people just really do not understand it. I am lucky in that my mother is an RN, so I can talk about things with her, but she has done it for so long, the little things that intrigue me tend to bore her, so this is how I decided to let it all out in a blog.
Enjoy.. and off to write my first little story...