Truth be told, I probably shouldn't be writing this post right now as exhausted as I am.
But today was such an epic day, I feel like I can't let a night's sleep go by without documenting it lest the urgency and intensity of these newly learned lessons fade away like a groggily remembered dream upon waking.
Today I was stretched to my limit in regards to knowledge, ability, precognition, skills... Any and every aspect of being a nurse was tested today. These are the days that make the battle for a position on a badass unit in an amazing hospital totally worth it.
I started the day with one patient. A complicated, but stable patient. I then admitted the first heart case out of the OR. The surgeon doing the surgery is known for his speedy technique, often he's done with CABGs in less than 2 hours.
Today's case took 5.
The patient was a re-do, having had a CABG x4 15 years ago. Today he had a CABG x2 and an AVR. The patient came crashing into the unit a little before noon with a SBP in the 50s. The anesthesiologist dinked him to get me enough BP to get him hooked up and a cardiac index shot. We got him started on epi, dobutamine, and levo. He was still tubed and was on propofol and precedex to boot. His index was crazy. His output was 7.5L, his index was 3.5, but his stroke volume was 40.3 and his SVR was 457... Whacked out numbers.
Once I regained a human BP in the patient, I then set about lowering it. This particular surgeon likes his MAP to be 55-65. Yes I know that the kidneys aren't being perfused at that pressure, and lord knows he's been told that a hundred times, but he doesn't care about the kidneys. He just doesn't want his slapstick grafts to bleed.
But that's a post for another day...
So I started weaning the epi and the levo, and ramped up the propofol and started nitroglycerin to bring his pressure back down. I finally get the patient stable with a SBP in the 70s, but a MAP of 55 just as the surgeon would like.
And then the brown stuff hit the proverbial fan. His rate shot up to the 120s, he dumped 400 ml out of his mediastinals in 45 minutes, his CVP dropped like a rock, and he started having PVC's and small 8-10 beat runs of v-tach. I crammed in 1250 ml of albumin, 3 units PRBCs and 2 units of FFP, and his hematocrit came up two lousy points.
Mercifully, he pseudo-stabilized and I thought all was good again, until I treated a 4.0 K per physician ordered protocol, and suddenly he has a 30 beat run(?) of v-tach and his SBP falls to the 50s again. He earned himself 2 grams of mag, an amp of lidocaine, and a lidocaine drip. He also just about sent me into SVT myself. Sent off a K level out of curiosity, and a 40 meq treat bumped his K from 4.0 to 5.2, all the while his urine output was >100 ml an hour. Tell me how that math works out!
But that wasn't even the hard part of my day.
This man's family was amazing. Sweet, sweet people, and very, very worried. But the complete trust and faith they had in me was staggering. And the sense of responsibility that generated was unexpectedly profound. I've always had a strong sense of duty to the patient--I'm well-versed in advocating for those that aren't able to stand up for themselves. However, the burden of care I experienced today was new to me, and it caught me by surprise a bit.
It struck me that where there was once an empty bed, a quiet, unoccupied space, now it was filled with love, worry, and concern. It was such a transformative experience--it was palpable in the air. My biggest fear was that I was going to let this wonderful family down. I have never worked so hard to stabilize a patient to date in my nursing experience.
Meanwhile, I was also counseling and supporting the wife of my other patient as she made the difficult decision to direct her husband's care from the western curative model to one of palliative care and a dignified end of life. She too was super sweet and so, so vulnerable. Hundreds of miles away from home and completely alone, she needed a great deal of help. The palliative care team was coordinating withdrawal of care as I left for the night.
Any day that I can learn something is a day not wasted. Any day I can be stretched to my limits without breaking is a blessing.
Today was a good day.
Friday, February 25, 2011
Wednesday, February 16, 2011
On The Other Side Of The Stirrups
I accompanied NurseXX to her first well-woman check-up since my son was born 2 years ago. Since the midwife group who presided over his birth only see OB patients, we were trying out a new OB/GYN.
As a healthcare professional, I tend to sit back and evaluate the experience perhaps with a little more objectivity than the average bear. Here's what I saw.
Our appointment was scheduled for 1330, and being new patients we were asked to arrive 15-20 minutes early to fill out paperwork. We arrived at 1310, and the doors were locked. When we were let inside the first interaction was, "Can I see your insurance card and drivers license?"
We were quite obviously the first appointment of the afternoon, given we were treated to listening to the lunchtime banter of a creepy, sleazy drug rep with the receptionists. Yet somehow we weren't shown back to the exam room until 15 minutes past our appointment time.
When we got to the exam room, the nurse took my wife's blood pressure manually, but did it so quickly there is no possible way she accurately heard any sounds. Oh, and inflated the cuff to 230 mmHG to start with. She then instructed my wife to change into a gown and drape after leaving a urine sample in the bathroom. Throughout the entire interaction, there was no greeting or "How are you doing?"
It was then that my wife realized the first time she'd meet the doctor, she'd be nude in a thin gown...
All in all the visit was actually a good one. The doc turned out to be super cool--she was very matter-of-fact, had an arm tattoo and a nose ring.
It just struck me that a few small changes could have made it a great visit, not just a good one.
As a healthcare professional, I tend to sit back and evaluate the experience perhaps with a little more objectivity than the average bear. Here's what I saw.
Our appointment was scheduled for 1330, and being new patients we were asked to arrive 15-20 minutes early to fill out paperwork. We arrived at 1310, and the doors were locked. When we were let inside the first interaction was, "Can I see your insurance card and drivers license?"
We were quite obviously the first appointment of the afternoon, given we were treated to listening to the lunchtime banter of a creepy, sleazy drug rep with the receptionists. Yet somehow we weren't shown back to the exam room until 15 minutes past our appointment time.
When we got to the exam room, the nurse took my wife's blood pressure manually, but did it so quickly there is no possible way she accurately heard any sounds. Oh, and inflated the cuff to 230 mmHG to start with. She then instructed my wife to change into a gown and drape after leaving a urine sample in the bathroom. Throughout the entire interaction, there was no greeting or "How are you doing?"
It was then that my wife realized the first time she'd meet the doctor, she'd be nude in a thin gown...
All in all the visit was actually a good one. The doc turned out to be super cool--she was very matter-of-fact, had an arm tattoo and a nose ring.
It just struck me that a few small changes could have made it a great visit, not just a good one.
Monday, February 14, 2011
Precepted. But.
Everyone knows what makes or breaks an internship depends a great deal on how well an orientee and preceptor fit together. Some people need that warm fuzzy super supportive hand holder. Some people need the hard ass whip cracker to keep them on the straight and narrow. Some need constant supervision, while others are best left alone until questions arise.
Now admittedly, I'm a difficult case to match with the proper preceptor. I have a great deal of knowledge because of my background, and I've run across preceptor type people that get intimidated--they get hung up on that and fail to see my willingness to learn.
I want to know why we do things, so I tend to ask numerous questions. "Because the doctor wrote an order," and "We just always do it that way," are the bane of my existence. But I also want to learn how you do things, although I may quickly find my own way. I am a very kinesthetic learner, so to really own skills I need to actually do them, although I can reason my way through tasks intellectually. I'm capable of being quite flexible, but that can mean while I appear to be holding my own, I may not be getting what I need to learn or function best.
I'm not sure what the perfect preceptor for me would look like, but I'm pretty sure it's not the one that I've been assigned.
Unfortunately.
The hospital has set criteria for us to meet that count towards our yearly merit raises. The idea is that nurses who contribute back to the workplace take ownership of their workplace, and make it an all-around better place to work. These criteria include teaching projects, community service, leadership roles, and...precepting.
My preceptor has been banned from precepting females, apparently because he has a habit of making them cry. Although I suspect there was some chauvinistic behavior that didn't impress the ladies too much either, particularly since he's married. He's not much of a teacher, or a community service kind of guy. It pretty much leaves precepting for him to get his chance at the full 5% merit raise.
But.
That doesn't seem to take into account whether or not he really should be precepting.
He has all the tools. He's one of the most senior people on the unit, and at 8 years of service that gives you the idea of the turnover we experience. (We have 6 people leaving for CRNA school in August.) He is very knowledgeable. He is in a leadership position on the unit, working as a charge nurse.
But.
He has no people skills. He is sexist, and he constantly makes suggestive comments to and about the female staff members. He takes shortcuts--all the time. He laughs in the face of paperwork, often saying that if an issue can be resolved in the course of the shift, then the paperwork doesn't need to be filled out.
But.
Everyone puts up with it, and nothing gets done or said.
Fine, not my problem, right?
But.
Example #1: Second day on the floor, I'm given a new admit from the OR--a lung decortication secondary to aspergillus infection. Never taken care of a patient with that procedure done before, but she was vented and sedated with propofol, on a few pressors, on an insulin drip, and a fentanyl drip for analgesia--no big deal. My preceptor helped me get her settled, and then I went about managing her care--I was only supposed to have the one patient being my second day and all. About an hour later, he gets a patient from another floor--a trachea erosion secondary to radiation for esophageal cancer waiting for a tracheal stent. Pretty unstable patient actually. We get him settled in the bed next to my patient, and the two have our four bed pod to themselves. Things were clicking along just dandy.
But.
Then he disappeared, leaving me by myself with the two patients for the remaining half of shift.
When the oncoming shift comes in for report, come to find out the way my preceptor had told me to run the fentanyl drips (mcg/hr) is very much NOT acceptable on our unit--unbeknownst to me. It turns out we have a weight-based analgesia protocol in place (1-3/mcg/kg/hr for fentanyl). On the patient I was originally taking, what I was giving was actually less than the weight based formula minimum.
But.
On the tracheal stent dude I was running at 400 mcg/hr to keep him pain free. He weighed 110 kg, and simple math tells you that our weight based max dose of fentanyl is 330 mcg/hr...I was running 70 mcg/hr above our protocol max thanks to my preceptor's cowboy shenanigans.
If the patient had crashed, or become say, hypotensive, (like patients receiving fentanyl are prone to doing,) it would have been my ass hanging in the wind. My hospital has made it very, very clear that as long as we stay within the confines of the policies and procedures, they will back us 100%. Step outside the shadow of those protocols, and we've been told, in no uncertain terms, we're on our own.
I'm sure he'd have been in trouble too, his license in jeopardy, but frankly I don't give a shit what happens to him. He put MY license in jeopardy, and I've had the damn thing for less than a month.
Now admittedly, I'm a difficult case to match with the proper preceptor. I have a great deal of knowledge because of my background, and I've run across preceptor type people that get intimidated--they get hung up on that and fail to see my willingness to learn.
I want to know why we do things, so I tend to ask numerous questions. "Because the doctor wrote an order," and "We just always do it that way," are the bane of my existence. But I also want to learn how you do things, although I may quickly find my own way. I am a very kinesthetic learner, so to really own skills I need to actually do them, although I can reason my way through tasks intellectually. I'm capable of being quite flexible, but that can mean while I appear to be holding my own, I may not be getting what I need to learn or function best.
I'm not sure what the perfect preceptor for me would look like, but I'm pretty sure it's not the one that I've been assigned.
Unfortunately.
The hospital has set criteria for us to meet that count towards our yearly merit raises. The idea is that nurses who contribute back to the workplace take ownership of their workplace, and make it an all-around better place to work. These criteria include teaching projects, community service, leadership roles, and...precepting.
My preceptor has been banned from precepting females, apparently because he has a habit of making them cry. Although I suspect there was some chauvinistic behavior that didn't impress the ladies too much either, particularly since he's married. He's not much of a teacher, or a community service kind of guy. It pretty much leaves precepting for him to get his chance at the full 5% merit raise.
But.
That doesn't seem to take into account whether or not he really should be precepting.
He has all the tools. He's one of the most senior people on the unit, and at 8 years of service that gives you the idea of the turnover we experience. (We have 6 people leaving for CRNA school in August.) He is very knowledgeable. He is in a leadership position on the unit, working as a charge nurse.
But.
He has no people skills. He is sexist, and he constantly makes suggestive comments to and about the female staff members. He takes shortcuts--all the time. He laughs in the face of paperwork, often saying that if an issue can be resolved in the course of the shift, then the paperwork doesn't need to be filled out.
But.
Everyone puts up with it, and nothing gets done or said.
Fine, not my problem, right?
But.
Example #1: Second day on the floor, I'm given a new admit from the OR--a lung decortication secondary to aspergillus infection. Never taken care of a patient with that procedure done before, but she was vented and sedated with propofol, on a few pressors, on an insulin drip, and a fentanyl drip for analgesia--no big deal. My preceptor helped me get her settled, and then I went about managing her care--I was only supposed to have the one patient being my second day and all. About an hour later, he gets a patient from another floor--a trachea erosion secondary to radiation for esophageal cancer waiting for a tracheal stent. Pretty unstable patient actually. We get him settled in the bed next to my patient, and the two have our four bed pod to themselves. Things were clicking along just dandy.
But.
Then he disappeared, leaving me by myself with the two patients for the remaining half of shift.
When the oncoming shift comes in for report, come to find out the way my preceptor had told me to run the fentanyl drips (mcg/hr) is very much NOT acceptable on our unit--unbeknownst to me. It turns out we have a weight-based analgesia protocol in place (1-3/mcg/kg/hr for fentanyl). On the patient I was originally taking, what I was giving was actually less than the weight based formula minimum.
But.
On the tracheal stent dude I was running at 400 mcg/hr to keep him pain free. He weighed 110 kg, and simple math tells you that our weight based max dose of fentanyl is 330 mcg/hr...I was running 70 mcg/hr above our protocol max thanks to my preceptor's cowboy shenanigans.
If the patient had crashed, or become say, hypotensive, (like patients receiving fentanyl are prone to doing,) it would have been my ass hanging in the wind. My hospital has made it very, very clear that as long as we stay within the confines of the policies and procedures, they will back us 100%. Step outside the shadow of those protocols, and we've been told, in no uncertain terms, we're on our own.
I'm sure he'd have been in trouble too, his license in jeopardy, but frankly I don't give a shit what happens to him. He put MY license in jeopardy, and I've had the damn thing for less than a month.
Saturday, February 12, 2011
The Gym Weeps For Me
Because I haven't been in over two weeks.
Lucky for me my weight has stayed stable, which is a small miracle considering my diet as of late. I can't believe how much time my job is taking from me. Right now I'm on dayshift for the purposes of orientation and the internship.
And it is absolutely killing me. I'm having to make choices like going to the gym or see my children.
I thought I'd have so much extra time when I started working. I mean, gone were the hours of studying for exams and writing up care plans of my nursing school days. I have a list of things I want to do.
Lucky for me my weight has stayed stable, which is a small miracle considering my diet as of late. I can't believe how much time my job is taking from me. Right now I'm on dayshift for the purposes of orientation and the internship.
And it is absolutely killing me. I'm having to make choices like going to the gym or see my children.
I thought I'd have so much extra time when I started working. I mean, gone were the hours of studying for exams and writing up care plans of my nursing school days. I have a list of things I want to do.
- Reading, other than text books.
- Writing a novel.
- Plant a garden.
- Do some home improvement.
- Learn to play guitar.
- Learn to play the bagpipes.
- Learn to paint.
- Actively pursue getting my photography in more galleries.
- Build a tent-top camping trailer to pull behind the Jeep.
- Do some upgrades on the Jeep.
- Camping/Backpacking trips.
- At least a 5K every month.
- Starting to ride a road bike and swimming so I can do my first triathlon.
- More travel: Scotland, Vancouver B.C., England, Germany, Austria.
Thursday, February 3, 2011
RN-BSN
It's official. I am licensed to practice in my state.
I postscripted my name with RN for the first time signing for anti-rejection meds from pharmacy. It was rather anti-climactic and the pharmacy tech didn't care.
A fitting end to one journey, and the beginning of another.
I'm loving my unit, the people I work with are top notch. Everyone is super smart and motivated. We've received our share of the crippling winter weather that grips much of the nation at the moment. When most of the city is flat shutting down, our unit is the only one in the entire 1000 bed hospital that hasn't had a call-in during the bad weather. That's a pretty good indicator of the level of commitment and the sense of duty my coworkers harbor.
I had my first patient family member give me a huge hug for the care I gave. It was a good feeling. The patient was a 46 year old CABG x5 jumps, who had never been sick a day of his life. His near heart attack was an earth shattering event for them. Judging from the way his wife clung to my neck as I was telling her goodbye after transferring them to our step down unit, I may have helped bring them some small measure of stability and hope.
Work has been exhausting due to the sheer volume of information to learn, and I haven't seen my family much because of the lengthy weather commutes. Overall though, it's been good.
I postscripted my name with RN for the first time signing for anti-rejection meds from pharmacy. It was rather anti-climactic and the pharmacy tech didn't care.
A fitting end to one journey, and the beginning of another.
I'm loving my unit, the people I work with are top notch. Everyone is super smart and motivated. We've received our share of the crippling winter weather that grips much of the nation at the moment. When most of the city is flat shutting down, our unit is the only one in the entire 1000 bed hospital that hasn't had a call-in during the bad weather. That's a pretty good indicator of the level of commitment and the sense of duty my coworkers harbor.
I had my first patient family member give me a huge hug for the care I gave. It was a good feeling. The patient was a 46 year old CABG x5 jumps, who had never been sick a day of his life. His near heart attack was an earth shattering event for them. Judging from the way his wife clung to my neck as I was telling her goodbye after transferring them to our step down unit, I may have helped bring them some small measure of stability and hope.
Work has been exhausting due to the sheer volume of information to learn, and I haven't seen my family much because of the lengthy weather commutes. Overall though, it's been good.
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