i got to work in the unit the other night at work. because we had an extra person, i got to actually shadow one of the rn's around for the night and participate in care. i got to focus care on one of the patients who was stable, but still on full support vent with trach collar.
she had been in there for 2 weeks and is now a bit more alert and oriented. unfortunately for her, the icp from the trach secretions has caused her to blow out all of the vessels in her eyes. it looked horrible. and painful, to me anyhow. so they were trying to d/c her soft wrist restraints (which are needed for most people on a vent who can be alert at times to prevent them from pulling out the tubes). her ativan drip kept going off as occluded.. i was told that with a drip only running at 5 cc/hr or if even at kvo, it can sometimes just not be enough to keep the line patent. we flushed the line... and she taught me that when flushing the cvc, to use positive pressure rather than just straight pushing. after that was finished, we decided to check her residual on her tube feeding and do the flush while we were in there. she had explained to the patient about trying to keep the restraints off while i was doing the flush. got her all straight in the bed and walked out. it wasn't 2 minutes later that she was trying to get up in the bed and had her feet half off of the bed. the nurse cut the light on, we got over there to get her back up when we noticed that her feeding tube had come out. i hurry up and shut it off so we don't have a huge mess, then go and get a new tube to put in while the nurse gets her straight back in the bed. lucky for me.. i get to put in the new ng feeding tube, which went so very well. no resistance, no coiling up in the back of the mouth.. straight on in. it was beautiful. and she was pissed. she was not a happy patient. i can understand... i wouldn't want all those tubes in me either. we just had to keep reminding her that it takes time to come off of all of this stuff and right now it was helping her. she finally took a good nap once her ativan started kicking back in. and we were able to leave the restraints off.. until she woke up.
she starts moving around in the bed again. i go in there, and she is very restless. i calmly but firmly tell her she cannot get up. help get her moved back in the bed. she keeps making a face at me and i can tell something isn't right. so i ask her if she is in pain. she shakes her head no. she burps and makes that face. the one that looks like move it.. vomit coming soon. i ask her if she feels like she is going to vomit. she shakes her head yes. in the meantime i am steadily keeping her hands down from pulling on her trach. i really didn't want her to pull it out. so i hook her hands up and go tell the nurse, who is in with another patient, that mine is nauseated. see they teach you in school (which i am sure this is common knowledge to all nurses, or it should be) that vomiting + intubation/trach/etc = aspiration. which is bad. so she is nauseated.. and i cut off the feeding. residual is 0. we assess and think it is probably just gas causing the nausea as her bowel sounds are hyperactive. since she cannot talk, we unhook her hands again so she can point to where the discomfort is. she points to her belly. responds yes to the pain question this time. she is actually cooperating quite well. then she wants to pull her hands up to her head again. the nurse says, "let's just see what she is going to do." she asks the patient, "do you want to scratch your nose?" she shakes her head yes. so we let her. she moves her hand ever so slowly up to her nose and then with the speed of lightning grabs that ng tube and starts pulling. what she didn't realize was that the nurse was ready for that and grabbed it at the tip of her nose and kept it in place. i giggled a bit and told her she couldn't take out the tube and pried her hand from around it. and so we hooked her back up, gave her some demerol for her pain, & let her sleep for a few more hours.
15 June 2006
12 June 2006
karma & supply shortages
last week i brought in an article on c. diff to my preceptor. for her reading pleasure, of course. but you see, it brought on the bad karma. the next night i come in to work and suddenly we have 7 patients on contact(and 2 of these on droplet as well) isolation... for c. diff (as well as a few choice other bugs added to a couple of them). i can imagine it was my payback for being a good little student. now here is the problem.
the c. diff article (published in AJN recently) stated how c. diff has been appearing in patients who are not on antibiotics. of course we all know that c. diff is highly contagious and can certainly be spread from patient to patient by not washing with soap and water before and after any contact with the infected patients. but it also brings up the point that it is possibly equipment that is doing a lot of the spreading, such as dinemapp's and portable thermometer's. ok. i can understand that too. not a problem to actually do things manually. however, whenever you have a good number of your patients on isolation, supplies can be an issue. heck they are an issue for a floor full of regular patients. hospitals (well the one where i work) can be stingy on sending supplies to the floors. i cannot tell you how often we are constantly "stealing" from another floor or dept because we have run out of something. and it isn't like the supply people work from 11p-7a either. hospital administrators need to address this issue and make it into some sort of policy. enough supplies should be kept on the floors to accommodate as if the floor was full at all times. perhaps if they had supply people who didn't bring up the stuff and just drop it where they see fit, we could find things. perhaps if they developed a system with bar coding, like in a grocery store, where we could check things out as we use them, they would know what to bring us the next day or later that evening before they leave. something else has to be more efficient than what we have now.
i watched a show on discovery or tlc the other night about a surgeon who developed a bar code system for checking surgical supplies to cut down the incidence of surgical supplies being left in patients after surgery. i think it is a novel idea that has uses in other areas of the hospital as well. after all, the pharmacy is able to keep track of all the medications and resupply as needed, why can't material management keep track of the supplies? are they not as important as the meds? it could even possibly be more cost effective in the long run as well.. perhaps.
the c. diff article (published in AJN recently) stated how c. diff has been appearing in patients who are not on antibiotics. of course we all know that c. diff is highly contagious and can certainly be spread from patient to patient by not washing with soap and water before and after any contact with the infected patients. but it also brings up the point that it is possibly equipment that is doing a lot of the spreading, such as dinemapp's and portable thermometer's. ok. i can understand that too. not a problem to actually do things manually. however, whenever you have a good number of your patients on isolation, supplies can be an issue. heck they are an issue for a floor full of regular patients. hospitals (well the one where i work) can be stingy on sending supplies to the floors. i cannot tell you how often we are constantly "stealing" from another floor or dept because we have run out of something. and it isn't like the supply people work from 11p-7a either. hospital administrators need to address this issue and make it into some sort of policy. enough supplies should be kept on the floors to accommodate as if the floor was full at all times. perhaps if they had supply people who didn't bring up the stuff and just drop it where they see fit, we could find things. perhaps if they developed a system with bar coding, like in a grocery store, where we could check things out as we use them, they would know what to bring us the next day or later that evening before they leave. something else has to be more efficient than what we have now.
i watched a show on discovery or tlc the other night about a surgeon who developed a bar code system for checking surgical supplies to cut down the incidence of surgical supplies being left in patients after surgery. i think it is a novel idea that has uses in other areas of the hospital as well. after all, the pharmacy is able to keep track of all the medications and resupply as needed, why can't material management keep track of the supplies? are they not as important as the meds? it could even possibly be more cost effective in the long run as well.. perhaps.
11 June 2006
truth takes time
you see, during my entire first year of school we focused upon support of each other. and then the support turned into expectations and lots of taking but no giving. i am all for supporting other students who are having problems... but not when it is taken for granted. these type of things can be deceiving for a long time, and many people do not see it in their desire to please everyone. however, there comes a time when you should see it for what it really is... and thus is why, truth takes time.
picture is from an episode of alias... where indeed, though unclear at the moment, the truth behind a situation is revealed eventually. my problem is that i cut off those people who were taking advantage of my helpfulness... i couldn't understand why i should work my tail off and they shouldn't have to.. only to be able to use the work i did.. such as all the work i did for our final in health assessment.. these people expected me to send them my notes.. didn't even bother working on it beforehand, just expected it. after that, i was finished. i was not going to do the work for several people.. i have my own self to worry about. i don't think i am being selfish, but how can people expect to pass nursing school riding on the coattails of others. well, truth be told.... several didn't pass into the second year, but there are a couple left in our program. but if you cannot bother to learn (not memorize!) the information, how can you expect to become a respected nurse and make responsible decisions and use any type of critical thinking? i just don't get it. anyhow, so this group that is left has banded together.. and made me the bad guy in the whole ordeal. because i refuse to let people walk all over me. because i had the courage to tell them that they really needed to do the work on their own and stop asking everyone else to do it for them. i am not trying to get the best grade in the class. i am trying to learn everything i can, including from my mistakes, so that i can pass the nclex and be a competent nurse. i don't have the time to play the silly mind games of classmates that are meant to drag a person down. i just don't have the time.
i know this is a downer post. nursing school is difficult enough without the interferences of teenage acting middle age women. i can only hope that there are others out there who may be going through the same dilemma. i just learned to say no. and it is telling when people stop talking to you or whatever because you decide not to carry them through anymore. i thought i had lost some good friends, but i guess they really aren't friends. the truth just took some time is all. ok.. i really must get to studying since we have another test next week. ciao!
picture is from an episode of alias... where indeed, though unclear at the moment, the truth behind a situation is revealed eventually. my problem is that i cut off those people who were taking advantage of my helpfulness... i couldn't understand why i should work my tail off and they shouldn't have to.. only to be able to use the work i did.. such as all the work i did for our final in health assessment.. these people expected me to send them my notes.. didn't even bother working on it beforehand, just expected it. after that, i was finished. i was not going to do the work for several people.. i have my own self to worry about. i don't think i am being selfish, but how can people expect to pass nursing school riding on the coattails of others. well, truth be told.... several didn't pass into the second year, but there are a couple left in our program. but if you cannot bother to learn (not memorize!) the information, how can you expect to become a respected nurse and make responsible decisions and use any type of critical thinking? i just don't get it. anyhow, so this group that is left has banded together.. and made me the bad guy in the whole ordeal. because i refuse to let people walk all over me. because i had the courage to tell them that they really needed to do the work on their own and stop asking everyone else to do it for them. i am not trying to get the best grade in the class. i am trying to learn everything i can, including from my mistakes, so that i can pass the nclex and be a competent nurse. i don't have the time to play the silly mind games of classmates that are meant to drag a person down. i just don't have the time.
i know this is a downer post. nursing school is difficult enough without the interferences of teenage acting middle age women. i can only hope that there are others out there who may be going through the same dilemma. i just learned to say no. and it is telling when people stop talking to you or whatever because you decide not to carry them through anymore. i thought i had lost some good friends, but i guess they really aren't friends. the truth just took some time is all. ok.. i really must get to studying since we have another test next week. ciao!
09 June 2006
What kind of nurse are you?
The place where I work seems to breed 2 types of nurses. Perhaps all places are like this? I don't know; I have only the experience of my place. In our place, we have the nurses that do, and those that don't. Do anything. By nurses, I am talking about our RNs. The one I work with most of the time, is one that does. She gets out on the floor, takes care of patients and all the while is still charge over the whole unit. On the other floor, those charge nurses sit at the desk all night and don't do. I overheard a conversation last night that postulated the type of school these nurses went to.. supposedly (hearsay is such a BAD thing) it was stated that they went to school to learn how to be a charge nurse. I butted in and said, "well it sure isn't where I go to school." They continued to make the comment that a nurse, no matter their degree or license, has to be able to do nursing stuff.. which includes vitals and wiping butts as well as assessments and orders and all the charting and paperwork. I sure told them that we get that full experience where I go to school.. we are taught to do. Get 'er done... is what my instructor taught us. I mean.. everyone can have time to take a break and sit for a few minutes... if everyone works together. I understand that different shifts have different responsibilities. I also understand that working nights on the floor spoils a person just a bit because of the lack of person-person interaction that we have... such as with families and doctors and such. But it doesn't mean that we don't work hard. Other shifts assume we don't work hard, but it's just different responsibilities.
There is one floor in particular that breeds these nurses that don't. The new ones come in and sees how those that have been there awhile do things... like sit at the desk and make the lpn's run their tails off while they sit there and say they are busy. They aren't busy, they can't be. We handle the same amount of patients on our floor and our 1 charge nurse (this other floor generally has at least 1 charge per 6 patients, while ours is 1 charge per 12 patients). Anyhow, the new nurses see how they do things, and thus it makes them become that way. Follow by example, right?
In that sense, I am lucky. If I follow by example, I will certainly not be one of those nurses. I will become a nurse that does. I even asked my mom.. after all, no matter what you can say about mothers, mine is brutally honest. So I asked her, "Mom, do you think I will be one of those nurses who will just sit at the desk and watch everyone work?" In her loving way, she replied," Nope... you don't mind getting out there and cleaning up poo." I hated to tell her I do mind, but it doesn't matter.. it has to be done, so it gets done. Get 'er done.
I see and hear how the nurses complain and have no respect for those nurses that don't... I don't want to be that nurse. I want to be one that has respect from my peers, one that they know will be there to help if it is needed. See I am learning something as an extern. So what kind of nurse are you?
There is one floor in particular that breeds these nurses that don't. The new ones come in and sees how those that have been there awhile do things... like sit at the desk and make the lpn's run their tails off while they sit there and say they are busy. They aren't busy, they can't be. We handle the same amount of patients on our floor and our 1 charge nurse (this other floor generally has at least 1 charge per 6 patients, while ours is 1 charge per 12 patients). Anyhow, the new nurses see how they do things, and thus it makes them become that way. Follow by example, right?
In that sense, I am lucky. If I follow by example, I will certainly not be one of those nurses. I will become a nurse that does. I even asked my mom.. after all, no matter what you can say about mothers, mine is brutally honest. So I asked her, "Mom, do you think I will be one of those nurses who will just sit at the desk and watch everyone work?" In her loving way, she replied," Nope... you don't mind getting out there and cleaning up poo." I hated to tell her I do mind, but it doesn't matter.. it has to be done, so it gets done. Get 'er done.
I see and hear how the nurses complain and have no respect for those nurses that don't... I don't want to be that nurse. I want to be one that has respect from my peers, one that they know will be there to help if it is needed. See I am learning something as an extern. So what kind of nurse are you?
code blue
I got to go to my first real code last night. As an observant. I was excited.. heart pumping.. thinking of all the things I would see when I got in there.. people rushing, meds going in, decisions made in seconds to save the person's life, the experience of seeing someone shocked for the first time..... so we get there, and it wasn't quite what I expected. It was a respiratory arrest that only required an airway. I have seen an intubation, so I made myself useful and helped pull things out to make room for the vent and answered the phone. I did get to see the RT bag someone, hadn't seen that yet.. but I still await the first real full code to watch. I need the experience of seeing it with observation so I can assess what is going on and take it all in. See what people do. It is amazing really.. in these type of situations. Everyone pulls together as a team and each person has their own role in the code/emergency situation. There is no arguing about who is doing what.. they just do. I respect that about those involved in a code, and all I could think was that when I graduate, and it is my turn to participate, I hope to hell one of these nurses is there with me! They know what the hell they are doing! :)
But I have to admit, when the er doc was intubating last night, all i could think about was that episode of er (yes I know.. it's not real and all of that, just things stick in your head) where pratt is intubating a kid and when he is lifting the neck for access, he breaks his neck. I could literally hear that crack inside of my head... of course that didn't happen last night, but I couldn't help thinking about it. Must stop watching er.
But I have to admit, when the er doc was intubating last night, all i could think about was that episode of er (yes I know.. it's not real and all of that, just things stick in your head) where pratt is intubating a kid and when he is lifting the neck for access, he breaks his neck. I could literally hear that crack inside of my head... of course that didn't happen last night, but I couldn't help thinking about it. Must stop watching er.
07 June 2006
scheduling mishaps & conversations while dreaming
tonight i go back into work... had to change my schedule to only work 8 h tonight... i tried to schedule just working three 12 h shifts to maximize my home, study and family time. luckily for me i am able to adjust my schedule as i need to, as tomorrow night i have to change my 12 h shift to only an 8 (again) because of baseball games and practices. When both kids are in different areas of town, it can be difficult to manage everything involved with the games and practices. so back to the 8 h shift I go.
tonight i get to work in the unit.. i love working in there. i especially love the monitors that already have the vitals all ready for you :) makes my job so much easier, plus i have time then to learn from the nurses that are working. i guess i will take in my school work to see if i might have sometime to work on that a bit in the slow periods. that's one bad thing about nightshifts... it can be verrrrrrry slow quite often.
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the other day while sleeping, my youngest son woke me up (love how they do that!) to ask me if he could walk up to the convenience store to get some candy. (normally I wouldn't care if he did, as long as he asked). i am not sure what i had been dreaming about, but i told him plain as could be that " no, you can't walk up that far. you have high blood pressure, and i would be very worried that something would happen to you." he looked at me and said so innocently, "does grandma know i have high blood pressure?" as soon as he asked me that, it dawned on me that i had been half talking in my sleep and i couldn't help but laugh at myself and told him "honey, no, nevermind, try not to talk to me while i am sleeping huh? you don't have high blood pressure, you are only 9!!" LOL i still get a giggle out of it... and it's things like that why i tell the boys do not wake me up for any phone calls while sleeping... i never know what i might say to people!
tonight i get to work in the unit.. i love working in there. i especially love the monitors that already have the vitals all ready for you :) makes my job so much easier, plus i have time then to learn from the nurses that are working. i guess i will take in my school work to see if i might have sometime to work on that a bit in the slow periods. that's one bad thing about nightshifts... it can be verrrrrrry slow quite often.
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the other day while sleeping, my youngest son woke me up (love how they do that!) to ask me if he could walk up to the convenience store to get some candy. (normally I wouldn't care if he did, as long as he asked). i am not sure what i had been dreaming about, but i told him plain as could be that " no, you can't walk up that far. you have high blood pressure, and i would be very worried that something would happen to you." he looked at me and said so innocently, "does grandma know i have high blood pressure?" as soon as he asked me that, it dawned on me that i had been half talking in my sleep and i couldn't help but laugh at myself and told him "honey, no, nevermind, try not to talk to me while i am sleeping huh? you don't have high blood pressure, you are only 9!!" LOL i still get a giggle out of it... and it's things like that why i tell the boys do not wake me up for any phone calls while sleeping... i never know what i might say to people!
05 June 2006
summer pharmacology
this is the second installment of the course. we had taken the first part in the fall last year. one thing is for sure, pharm isn't for those who don't take the time to study and review the material. my biggest issue with this class this summer is that we have no class time/no lecture time at all. we are self-directed, teach this to ourselves, then go in and take a total of 3 tests for the "semester."
my biggest issue with myself is that i am so lacking in the self direction part. i just do not want to study anything at all right now.. just want a break so i can be fresh in the fall for psych. i am lucky that we have at least already worked with the cardiac and respiratory meds so i do have a foundation.. it is just remembering all of it for the tricky test questions.
tomorrow is our first test.
with so few tests, i really pray that i pass the test...
not that i am afraid of failing,
i just know how difficult it is to make up the scores to get above an 80.
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* Update: Passed my test *smile* phewwwwwwww :)
my biggest issue with myself is that i am so lacking in the self direction part. i just do not want to study anything at all right now.. just want a break so i can be fresh in the fall for psych. i am lucky that we have at least already worked with the cardiac and respiratory meds so i do have a foundation.. it is just remembering all of it for the tricky test questions.
tomorrow is our first test.
with so few tests, i really pray that i pass the test...
not that i am afraid of failing,
i just know how difficult it is to make up the scores to get above an 80.
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* Update: Passed my test *smile* phewwwwwwww :)
01 June 2006
Poo Poo and yes, More Poo
One of the things they don't tell you before signing up for nursing school is just exactly how much poo you get to observe and evaluate for its color, consistency, amount, and unfortunately, the odor is an added bonus, and I cannot forget being prepared to scoop for specimens. One thing is for sure, nurses must have a keen sense of smell and a strong stomach. They can identify the differences between tube feeding poo, c diff poo, gi bleed poo, iron poo, and so on. And it is always good to have something special that helps sidetrack the odor once a whiff is in... we use shaving cream, a cheap odor buster that doesn't irritate the bottom.
These past few days, I got christened with starting my first tap water enema. I worked the floor with my first year instructor -- she was excited for the experience it would give me. I wasn't necessarily thrilled, the pt drank the whole gallon of golytely and didn't go one time the entire shift---- so I knew it was not going to be pretty. And it wasn't. The pt was being prepped for a colon, however it was a no go. After the 3rd one, it was clear the pt would not be having that colon that morning. It would have to wait for the next day. I felt so bad for the pt. Over 90, state dnr, but yet the dr insisted on the colon d/t the possibility of a lower gi bleed. After the colon was finally done, nothing was found. There was probably a bleed somewhere, but they do not know where. That night after the colon, they had to be transfused with 3 units prbc. And this was nothing new for the pt as they have had multiple transfusions over the past few months. My preceptor didn't think the pt would make it through the night, that all of this was too much for them to handle. They were still alive when we left this morning, and hopefully they are still alive by the time I go back on Saturday.
Sometimes, I just wonder when enough is enough as far as taking into account the person's age and etc. I have seen them do a colon upstairs, it's not pretty. If I am over 90, just LET ME BE. I think I will create a do not do these procedures on me list for when I am that old. If I make it that long, I expect to be able to eat what I want, or what I can. Drink what I want, and golytely isn't going to be on that list. Sign me right up for comfort measures only, and let me enjoy my last days in peace. Just turn me over every 2h so I don't break down.
And I just wanted to do a small update on the intubated pt from the previous post. They had been extubated, but the sats fell down to 19% and they were coded and reintubated. It's unclear whether or not they will be able to come off of the vent. The tracheal deviation was d/t a mass pressing on the trachea. However, they were flown out to a bigger hospital yesterday, but I don't know why. It's obvious the condition was much more critical than we could handle.
These past few days, I got christened with starting my first tap water enema. I worked the floor with my first year instructor -- she was excited for the experience it would give me. I wasn't necessarily thrilled, the pt drank the whole gallon of golytely and didn't go one time the entire shift---- so I knew it was not going to be pretty. And it wasn't. The pt was being prepped for a colon, however it was a no go. After the 3rd one, it was clear the pt would not be having that colon that morning. It would have to wait for the next day. I felt so bad for the pt. Over 90, state dnr, but yet the dr insisted on the colon d/t the possibility of a lower gi bleed. After the colon was finally done, nothing was found. There was probably a bleed somewhere, but they do not know where. That night after the colon, they had to be transfused with 3 units prbc. And this was nothing new for the pt as they have had multiple transfusions over the past few months. My preceptor didn't think the pt would make it through the night, that all of this was too much for them to handle. They were still alive when we left this morning, and hopefully they are still alive by the time I go back on Saturday.
Sometimes, I just wonder when enough is enough as far as taking into account the person's age and etc. I have seen them do a colon upstairs, it's not pretty. If I am over 90, just LET ME BE. I think I will create a do not do these procedures on me list for when I am that old. If I make it that long, I expect to be able to eat what I want, or what I can. Drink what I want, and golytely isn't going to be on that list. Sign me right up for comfort measures only, and let me enjoy my last days in peace. Just turn me over every 2h so I don't break down.
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26 May 2006
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.
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.
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