tag:blogger.com,1999:blog-90274982285201722572024-02-02T17:02:58.600-06:00nurseXYRoberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.comBlogger181125tag:blogger.com,1999:blog-9027498228520172257.post-20593983666118535502012-10-05T11:03:00.000-05:002012-10-05T11:05:46.450-05:00RCARemember this guy? <a href="http://nursexy.blogspot.com/2011/03/dr-slapstick.html">Dr. Slapstick</a>?<br />
<br />
Well, a couple months ago Dr. Slapstick reverted back to his old habit of doing 3 cases in a day.<br />
<br />
He's been explicitly <strike>asked</strike> told not to do this. But, since he is the medical director, there is little oversight regarding his practices. Essentially the top echelon of administration has to get involved if there's any issue with him or his practices. And we all know how fast administration moves--like I've seen glaciers move faster...especially in this day and age of global warming.<br />
<br />
Anyway, Dr. Slapstick's 3rd case of the day comes out on night shift, about 8 pm. <br />
<br />
The patient is a 47 y/o female patient getting a valve repair. It's her 5th valve surgery. She had congenital valve problems--two surgeries as a child performed by some other obviously competent surgeon.<br />
<br />
The next three surgeries were performed by our very own Dr. Slapstick. In fact, the reason for the 5th surgery is because Dr. Slapstick damaged a leaflet of her aortic valve during her 4th valve surgery.<br />
<br />
Oops.<br />
<br />
Now, because of all these previous surgeries, Dr. Slapstick decided that the sternal/mediastinal scar tissue would be so bad he needed to take a different approach--like between the posterolateral ribs, much like a thoracotomy. The anesthesiologist/perfusionist decide to cannulate the femoral artery and vein.<br />
<br />
This is an excellent piece of clinical decision making. CT surgery is moving towards the minimally invasive route as a whole, and scar tissue on sternotomy reentries can be a real problem.<br />
<br />
Except I have never seen Dr. Slapstick do this particular surgery from this particular approach. <br />
<br />
Ever.<br />
<br />
And this case ends up with an 8 hour pump time.<br />
<br />
Regardless, the patient comes out with rock steady vitals, on very few vasoactive drips, and minimal bleeding (especially for Dr. Slapstick). Orders are to sleep the patient for 2 hours, then wake her up and extubate.<br />
<br />
Well, along comes 2 am, and the patient has been off propofol for 4 hours and is still not responding. The night nurse is concerned (rightfully so) but the night charge nurse advises against calling the physician. You see, Dr. Slapstick has three cases scheduled the next day.<br />
<br />
Night nurse, (God bless her, she's awesome!) decides she's going to call anyway.<br />
<br />
Dr. Slapstick yells at her, "I can't believe you are calling me about this!! I mean really?!? I have a 6 am case!! Just turn the propofol back on and we'll deal with it in the morning." Which she documents in real time, word for word, with quotation marks.<br />
<br />
Next morning this patient is half of my assignment, and the night nurse relays all this to me in report. I immediately start weaning down the propofol, and perform a thorough shift assessment. Pupils are a 2 and sluggish, and all the primitive reflexes I test are present.<br />
<br />
By 8 am, I'm off propofol completely. The patient is unresponsive. Dr. Slapstick comes by shortly after. He's still miffed about being woken up the night before, assesses the patient, and tells me to continue what I'm doing.<br />
<br />
At 10 am, the patient is still unresponsive, and isn't over-breathing the vent. I'm getting concerned, and my nursing spidey sense is going off like a klaxon horn on the bridge of a WWII warship. I do another full neuro assessment.<br />
<br />
Oh crap.<br />
<br />
Right pupil 3 and veeeerry sluggish. Left pupil 8 and fixed. No gag, no corneal. Potential toe flare on babinski. I can barely hide my concern from the patient family as I dash for the phone to call Dr. Slapstick.<br />
<br />
Dr. Slapstick is in the OR. I relay the message through the circulating nurse, and the reply, incredibly, is to turn the propofol back on, and he'll be out to assess the patient when he's through in about an hour.<br />
<br />
I ask for a neurologist consult, but do not receive one. I ask for a head CT, but do not receive one.<br />
<br />
Completely dissatisfied, I call the anesthesiologist who worked the case, trying to get a back door order. The anesthesiologist is unwilling to countermand Dr. Slapstick. The charge nurse calls the house supervisor, who calls administration. Nobody is willing to go out on a limb.<br />
<br />
The hours creep by. Calls to Dr. Slapstick's OR reveal his current case is not going well. Complications abound. I've updated the family, because that's what I do. I don't lie to families, and I keep them informed. They are besides themselves, and I am too.<br />
<br />
Dr. Slapstick finally shows up at the bedside 4, (FOUR!!) hours later. Does a quick 5 minute exam and has me consult a neurologist. The neurologist is at the bedside within 10 minutes, does his exam and we are in the CT scanner in another 10 minutes. The neurologist stays in the control room with us and reads the CT slice by slice as it comes up.<br />
<br />
Massive diffuse global anoxic injury. Oh and she's partially herniated, and it's progressing.<br />
<br />
After meeting with the neurologist the patient's husband tells me he's preparing himself for the hardest conversation of his life. He's headed home to tell his 5 year old daughter that her mother isn't coming home.<br />
<br />
---------------------<br />
<br />
Two weeks later I get summoned to a Root Cause Analysis (RCA) for this patient's "unexpected negative outcome." Dr. Slapstick proceeds to attempt to blame the entire debacle on nursing, stating that we "failed to communicate the seriousness of the situation to him."<br />
<br />
All I can say is thank goodness for thorough charting and for my less than shy mouth. And my healthy belief that doctors put their pants on just like everyone else.<br />
<br />
One leg at a time.<br />
<br />
Two days later, there's a note up in the break room on the unit from Dr. Slapstick. It seems he's leaving to pursue other opportunities in an outlying community where he has the privilege to develop a CT surgery program. He trips all over himself thanking us for the excellent care we always gave his patients.<br />
<br />
Sometimes administration finally does get it right.<br />
<br />
I'm sure the patient's 5 year old daughter really appreciates that.Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com9tag:blogger.com,1999:blog-9027498228520172257.post-39422414021788409092012-10-03T10:09:00.000-05:002012-10-03T10:10:36.746-05:00Nightmare ShiftJust another morning in the ICU (or so I think) as I walk up to the front nurses station to get my assignment.<br />
<br />
I see my name next to a pair of patients, but then I notice it's also next to another pair of patients, but on the other side of the unit. <br />
<br />
"Hey Tracy," I call to the night charge nurse, "I think you've got me double assigned here."<br />
<br />
"Weeeelll," she hedges, "Not really. These two will be your assignment, but I need you to take these two also. But just until their rooms are clean."<br />
<br />
She can tell by my face, I'm sure, that I'm much less than thrilled.<br />
<br />
"Don't worry, It will just be for a few minutes and you just have to wheel them upstairs, the night nurse already called report."<br />
<br />
It occurs to me that the charge nurse, or the night nurse, seem quite capable of "just wheeling them upstairs". I mean, I've heard of being tripled, but quadrupled?! In the end though, I grudgingly accept the assignment.<br />
<br />
By the time I get report on my two "real" patients, the unit secretary lets me know that the room is ready for one of my "fake" patients. I glance in on my other patients to make sure they are breathing, load him up in a wheelchair and head for the elevators.<br />
<br />
Once I return from settling him, the unit secretary tells me the other room is ready as well. Maybe this is going to work out just like the charge nurse intended. But that scares me almost as much as the stupid assignment, because if it does work, they'll be inclined to do it again.<br />
<br />
When I go into the other room, the first thing I notice is that the chest tube atrium is almost full. Knowing full well the floor nurses will bitch and moan about having to change it (and also a high likelihood they'll refuse to accept the patient until it's changed) I head to clean supply for a fresh atrium. <br />
<br />
I fill the atrium with the blue water (same color as the water in porta-johns, think about THAT for moment), clamp off the chest tubes, and make the new connections. It's only when I slide the old, full one over that I notice the TWO other old, full atriums hiding under the end of the bed. <br />
<br />
Now realize, I haven't gotten any kind of report on this patient. I really have no clue what's going on with him, even really what surgery he's had. I assume he's had some sort of CT surgery, given the fact he has chest tubes in. I pause, contemplating the significance of THREE full atriums. I mean surely the physician knows, right? Surely he wouldn't have written floor orders if it wasn't a resolved issue, right? <br />
<br />
Right?<br />
<br />
I turn around and happen to look at the fresh new atrium.<br />
<br />
The first chamber is already full.<br />
<br />
As in 200 mls of fresh, frank blood. And as I watch, the level is steadily rising. <br />
<br />
Ah crap.<br />
<br />
I grab the chart to find out which physician I need to call.<br />
<br />
Great. Dr. Ballantine. I have NO clue who he is, not one of our regular surgeons. I fumble around, and find a cell phone number in the progress notes. <br />
<br />
Ring. Ring. Ring.<br />
<br />
Finally a very tired doc answers the phone, "....Hullo?"<br />
<br />
"Dr. Ballantine?"<br />
<br />
"...yeah?"<br />
<br />
"Your patient Mr. Soandso is bleeding quite badly into his chest tubes."<br />
<br />
"......"<br />
<br />
"Um, I have 3 full atriums here, and he's put out 200, no, 400 mls now, in the last 10 minutes."<br />
<br />
"......"<br />
<br />
"Uh, sir?"<br />
<br />
"What do you want me to do about it?" he slurs.<br />
<br />
Dumbfounded, I stand there for a moment, only to be shaken from my reverie by the monitor alarming. Guess whose pressure is now in the 60s. He's also gone unresponsive. I set the phone down on the counter to check a pulse.<br />
<br />
Of course there is none.<br />
<br />
I immediately leap up on the bed and start compressions.<br />
<br />
"I need some help in here!!" I yell.<br />
<br />
But nobody seems to be coming. I yell a second time.<br />
<br />
Nobody.<br />
<br />
Finally, I lean to the head of bed and while continuing compressions one handed, I mash the code button. Now, normally we don't use the code button--we run our own codes. Pushing the code button results in a room crowded too full of overeager, yet usually semi-clueless residents and interns.<br />
<br />
Today is no exception.<br />
<br />
My knight in shining armor turns out to be a first year resident. I'm immediately reminded of the 4F's of a gallbladder differential diagnosis--Fat, Female, Forty, Fertile. With huge boobs. I wonder abstractly if her stethoscope is long enough to reach past her boobs?<br />
<br />
She immediately decides my patient needs to be intubated--which is the most ridiculous thing to be concerned about at this particular moment. No pulse, no pressure, probably no blood because the damn atrium is full again and the chest tubes look like red garden hoses. And, since the patient was headed to the floor, no central access. I tell the resident so. She is clearly very pissed, but stops the intubation charade.<br />
<br />
The room is filling up now, and someone FINALLY brings in the crash cart.<br />
<br />
And of course, here comes RT trundling in with a vent. The vent alarm is continuously going off, "Circuit Disconnect, Not Ventilating!!"<br />
<br />
Only then I realize, it's my cell phone alarming. And I'm home in bed.<br />
<br />
Dreaming.<br />
<br />
Awfully tiring working a shift in your dreams at night between two day shifts.Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com3tag:blogger.com,1999:blog-9027498228520172257.post-20644717572426600572012-10-02T20:21:00.001-05:002012-10-03T10:11:07.817-05:00ReportNight nurse: (Flopping chart down on desk, and sighing dramatically.) "The shit really hit the fan with this patient last night!"<br />
<br />
Me: "Oh really!? What happened?"<br />
<br />
Night nurse: "Well one minute I was looking at the monitor and her heart rate was in the 90s, and then the next minute she was in the 130s! All I did was turn her! She totally went into a-fib with RVR!!!!"<br />
<br />
Me: "Uh huh, then what happened?"<br />
<br />
Night nurse: "Nothing. It was really BAD!"<br />
<br />
Me: "....oh."<br />
<br />
(76 y/o female patient in the ICU for COPD exacerbation, on 5mcg/kg/min of dobutamine for her heart failure.)Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com2tag:blogger.com,1999:blog-9027498228520172257.post-32170090836317528282012-01-02T20:49:00.003-06:002012-01-02T21:35:54.278-06:00Christmas Eve & The EndLikely this will be the last post here on NurseXY. I haven't written in awhile, and rest assured it's not because I haven't had ample blog fodder. In fact, it seems that every single shift I work offers up at least one or two events that seem blog worthy. So much so that I find myself realizing that if I blog about one situation, 3 or 4 more are just as pertinent.<br /><br />I suspect that this is simply the nature of nursing. Or at least nursing on my unit, and it's time to get over myself and my nursing experience. Likely you as RN's (or other medical professionals) have the same experiences. Mine aren't any more valuable.<br /><br />A few have emailed checking to see if I am ok, so a small update: I am now on day shift, have been since back in June or July. Day shift on our unit is nuts. I've never worked so hard in my life. But this is good, I don't (can't) get lazy. I enjoy getting regular admits from the OR, and I enjoy interacting with physicians on a daily basis. (They are amazingly friendly when you aren't calling them at 0200!) I've managed to develop a bit of a positive reputation with a few of them even. Recently, after hearing my name called on the overhead PA requesting help for about the 10th time that morning, a patient of mine commented, "Boy they'd be a little lost without you, wouldn't they!?" It was a truly meaningful compliment. And I feel like I pull more than my weight.<br /><br />Life isn't all roses though. I have trouble with my manager--I'm relatively sure that she's a large reason why the unit has many of the issues it does. I tend to be outspoken, and I tend to emphasize the things that truly matter (like patient care, patient safety etc) and let the bureaucratic things slide. Unapologetically. Not terribly popular with management.<br /><br />Regardless, as I come to the end of this blog here, I thought I'd like to leave you with one last post, and a positive one at that.<br /><br />I was scheduled to work on Christmas Eve and Christmas Day this year, and Christmas Eve's shift was nutso. The entire day was ridiculous, and doing a bedside surgical trach revision at 1825 (20 minutes before shift change) pretty much was the cherry on top. Needless to say, I was late leaving and there were very few vehicles on the road as I drove my 42 miles home in the clear, cold darkness. As I passed through a particularly rural portion of my drive, my thoughts couldn't help but wander to the Christmas story of the shepherds tending their flocks that first Christmas Eve so long ago. And I as I reflected, I began to see a parallel with the shepherds in the fact that I was out and about in service of others in need while most people were safely snug at home. <br /><br />And it was then that I realized, all those people with food in their bellies, a warm home wrapped around their shoulders like a coat of contentment? They would have completely missed Christ's birth. Their feet would have been comfortably propped by the fire, telling stories or playing some silly card game.<br /><br />As the story goes, not so Joseph and Mary. They ended up in a stable because they were in desperate need, and a humble barn was the best they could scrounge--offered only as a second thought.<br /><br />If Christ had been born in 2011, on some tattered greasy couch in some mechanic's shop in the slum of some city, who would have been there to witness it? To welcome God incarnate? The well to-do? The church goers at Christmas Eve service? <br /><br />So my thought is simply this: it is where service and human need come together that the spirit of Christmas can truly be revealed and we can experience the face of God.<br /><br />Merry Christmas, and may God bless us, everyone.<br /><br />Sincerely, <br /><br />Robert Fenton RN-BSNRoberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com18tag:blogger.com,1999:blog-9027498228520172257.post-21615878313597565142011-10-28T22:55:00.002-05:002011-10-28T23:11:00.480-05:00Where Has All The Goodness Gone?Alone.<br /><br />At home in the living room.<br /><br />Kids in bed. Wife at work.<br /><br />And I'm searching for the good. The TV is on--an episode of HouseHunters International. A woman is moving to Paris after battling Stage 3 breast cancer and losing her husband over the last year. <br /><br />She's looking for the good.<br /><br />When the show is over, she's happy in her new apartment in a beautiful, romantic city.<br /><br />My eyes scan the shelves of movies we own, and come to rest on "The Sound of Music". It doesn't get much more good than that. My mind examines why this is? It was a time when there was a definite line in the sand. On this side was the bad. On this, the good. One was the enemy, or not. <br /><br />70 years later it looks pretty black and white.<br /><br />But what if the enemy is within? <br /><br />Where has all the goodness gone?<br /><br />I live in a comfortable home--a dream completely out of reach for many. Yet I want to move. I long to live in another place. Anywhere but here, really.<br /><br />I have a job--the deepest desire of many. It used to afford me moments of joy. Delight in saving lives. But now I struggle to tiptoe through each shift worried more that I will do something that will get my hand slapped, or worse.<br /><br />I am married--and so many are so alone. But I struggle to maintain even the simplest lines of communication. The specter of my insecurities and past hurts and grievances shadows over all.<br /><br />I have kids--while so many are desperate to bear children of their own. One child that no longer wants to live with me. And my bearish tendencies and low patience threshold send the other two to my wife's welcoming arms.<br /><br />I feel so very grey.<br /><br />Where, oh where, has all the goodness gone?Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com8tag:blogger.com,1999:blog-9027498228520172257.post-5205122595879665692011-10-27T21:01:00.001-05:002011-10-27T21:03:16.807-05:00Alone"We're born alone, we live alone, we die alone. Only through our love and friendship can we create the illusion for the moment that we're not alone."<br /><br />--Orson WellesRoberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com3tag:blogger.com,1999:blog-9027498228520172257.post-84656016775933310852011-10-18T10:37:00.000-05:002011-10-18T10:37:01.012-05:00PerspectiveSunday I worked--another insane shift, and another insane assignment. But that's another post.<br /><br />I was assigned to our reverse isolation pod where we put our heart and lung transplants. I was assigned two very sick transplants with complications, but across the pod was a fresh lung transplant from Friday. When I came on shift he was doing pressure support trials in preparation for extubation. He was pretty anxious--as most people intubated without sedation are--but even more so because he was a lung patient.<br /><br />He passed his trials with flying colors and was quickly extubated. His family came in afterwards, thrilled to be able to talk to him. The family was bubbling over with happiness and enthusiasm, which is pretty typical of post transplant patients and families. They are just so thankful that their loved one has been granted a second chance afforded them by their new organs.<br /><br />The patient was doing his best to match his family's mood, but it was pretty clear to me that he wasn't doing as well as he was making out. His wife kept asking him if he felt better, and he would agree that he did, managing a tentative smile for her. <br /><br />He was a little more forthcoming with his nurse when the family wasn't present. He admitted to some pain and feeling somewhat short of breath. He also was pretty fatigued. Most of all he was just tired of being in a hospital bed with all the ridiculous lines and tubes we insist on attaching. And rightly so I think--we do tend to take things a little far with what we expect our patients to tolerate. He had come to our hospital from 750 miles away for the transplant consult, and it had taken 10 months to get where he was because of some other complications that needed to be resolved before he was a true candidate. Imagine being away from home temporarily...but for 10 months. Did I mention we don't have TV's in our open pods? In short, he was just cranky.<br /><br />A couple hours later I overheard him ask his nurse how much of the surgery he would be awake for. I stopped what I was doing to look across the pod and listen in.<br /><br />The nurse gave him a blank look and asked, "What surgery?"<br /><br />A little annoyed, he shot back, "The one I've only been waiting 10 months for!?"<br /><br />"Uh, you had your surgery on Friday, today is Sunday."<br /><br />His turn to give a blank look.<br /><br />She repeated, "You got your lungs on Friday, you've had your transplant already."<br /><br />"No shit??" A slow smile spread across his face. <br /><br />Thanks to the anesthesia the last thing he remembered was changing into a gown...<br /><br />It's amazing to see the shift in his perspective and his mood based on that one small piece of information. Suddenly he was pleasant, jovial even. He was happy to see his family, even when they stayed to long, or asked him for the 50th time, "How do you feel? Are you better??"<br /><br />So let me ask <span style="font-style:italic;">you</span>, when <span style="font-style:italic;">you</span> woke up this morning, did you face the day like it was gift? Like you had been blessed with a new set of lungs?<br /><br />Or are you still waiting (for 10 months now!) for something good to happen?<br /><br />If I may draw from the wisdom of Frog on the kids show <a href="http://www.nickjr.com/little-bear/">Little Bear</a>, (a favorite in my house), "A day is just a day. It isn't good or bad." <span style="font-style:italic;"> We </span>decide if it's good or bad.<br /><br />What will you do with your new lungs today?Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com2tag:blogger.com,1999:blog-9027498228520172257.post-68644552095170537112011-10-15T10:19:00.002-05:002011-10-15T10:20:06.950-05:00You Might Be...You might be a nurse if:<br /><br />You start a vitals/medication flowsheet at home when a family member is ill...Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com3tag:blogger.com,1999:blog-9027498228520172257.post-46362076881730604042011-10-14T09:25:00.000-05:002011-10-14T09:39:58.686-05:00Pay DayMy wife and had a financial meeting this morning, as we often do on the morning after our paychecks get direct deposited into the checking account. Usually it's a quick assessment of what little we have to show for our hard work after the dust clears from the bills feeding frenzy.<br /><br />Today was no different.<br /><br />However, we did a quick check of our gross income to make sure that we were on track with our tithe amount for church. And that's when it hit me.<br /><br />My gross pay for the year (with numerous extra shifts and overtime) was just over half of my wife's gross pay to date. Right at 55%. My wife doesn't often work extra shifts (although she has occasionally.)<br /><br />Let me qualify this observation:<br /><br />a.) She has been at her job for 9 years, I for less than 1 year.<br /><br />b.) She works a contracted weekend plan that pays her an extra differential for working every weekend.<br /><br />Ok, so she's had a significant head start, and she gets compensated for forking over our social life essentially.<br /><br />But twice as much? Really??<br /><br />She works for a nationally recognized non-profit children's hospital. It is a large hospital--over 300 beds, and expanding even as we speak. It is a designated trauma center. She works on a critical care unit at the highest level of care provided by the hospital to its patients.<br /><br />I work for a nationally recognized non-profit hospital. It is a large hospital--over 1000 beds, and expanding even as we speak. We are designated a Level 1 trauma center. I work on a critical care unit at the highest level of care provided by the hospital to its patients.<br /><br />New grad nurses at her hospital make on average at least $10,000 more per year than new grads at my hospital.<br /><br />My wife gets paid extra for working in critical care. I get paid the same as any other nurse in the hospital--day surgery to med-surg to L&D. We all get paid the same.<br /><br />I recently remember working a weekend (extra diff), night (extra diff), holiday (time & a half), overtime (time & a half) shift. After adding up all my diffs and overtime, my hourly pay was only slightly more than my wife's base pay.<br /><br />I don't mind that my wife makes more than me, at least not consciously. In fact I'm quite thankful as her job is the only way we've survived financially through my job failures and extra degrees. But when I think about how hard I work and the razor edge I routinely walk with my patient's lives and my license, it is a little disheartening to see the disparity. I don't think my wife works any less hard than I do, but I don't think she works any harder either.<br /><br />Because of my past degrees, I have a crippling amount of student loan debt. Two of my three loan payments were more than this 2 weeks paycheck, and the third loan payment will be another 1/3 of my next paycheck. Lucky for me, the end of those payments is in sight--only 29 1/2 years from now. <br /><br />I guess like many, I'm lucky to have a spouse willing to lump her paychecks into the joint checking account to provide for her family. <br /><br />So sweetie, "Thank you," for paying my car payment this month, and my insurance, groceries, and fuel. Oh and "Thanks" for providing me a place to live.<br /><br />I'll do my best to repay you when I get my earning potential soul back from the student loan companies. <br /><br />Either that or when my life insurance comes through.Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com7tag:blogger.com,1999:blog-9027498228520172257.post-57417251448333261872011-10-12T21:20:00.005-05:002011-10-12T21:53:58.598-05:00If It Isn't Charted...It Never......happened. <br /><br />I generally regale you, my faithful readers, with stories of my wild successes. Usually I play the distinguished (if not a little crusty) hero with some great over-arching theme to impart upon the nursing masses.<br /><br />Not today.<br /><br />Today I was called into the office for a closed door conference with the unit educator and the unit manager. The door closing behind you is pretty much a fateful sign. You're not escaping without some pound of flesh taken in payment.<br /><br />All this over a shift that was an ass-kicking from the start. Two very sick patients--one in severe septic shock, and the other most likely in the same situation. One was on hemodialysis, the other on CVVHD. A handful in and of itself, but across the pod lay a 180 kg woman who was to be taken for a CABG. Only the night shift nurse had pulled the PCI sheath, held pressure for 4 minutes flat, determined the patient wasn't bleeding externally from the site, and called it a day. It wasn't much later that the patient developed a football sized hematoma. That grew to be basketball sized while her pressures cratered from the shock of it all. Not hard to do when your ejection fraction is <15%. <br /><br />Meanwhile that patient's nurse was chasing herself silly trying to get her other patient transferred to the floor because the first case of the day needed to go into that bed for staffing reasons. As in, we didn't have staff to take that case. When she left to transfer her patient, I was tasked with watching her other patient's hematoma grow.<br /><br />I was left to doppler distal pulses and set up a C-clamp to hold pressure on the femoral artery to prevent the hematoma from growing any bigger. All the while maintaining some semblance of hemodynamic stability. I had just turned the patient's levophed up to our unit's max dose to maintain a pressure in the 60s (nothing like squeezing a dry tank, right!?!) when my patient on hemodialysis bottomed her pressures in response to the fluid draw. So away I went to titrate some pressors to maintain a MAP above the renal injury threshold. Just as I was about to get her settled, my CVVHD patient clotted her filter. And it was while I was attempting to rinse back the 200+ mls of blood in the machine that the anesthesiologist and anesthesia tech appeared to take hematoma lady to the OR. <br /><br />It was a dangerous situation. Did I mention my charge nurse was off the floor kissing Joint Commission ass with the manager--we were being recertified for LVADs you see. <br /><br />I had no help.<br /><br />I spent the rest of the shift trying to catch up on my charting while taking care of two still very sick patients. Towards the end of the shift one of my patients began breathing at a rate greater than 50. She was intubated, but not sedated, and pressure support CPAP-ing. (Recipe for disaster really since we were not about to extubate her...) <br /><br />My calls to physician essentially fell on deaf ears. I received orders to increase the pressure support, but nothing else. I complied, and at shift change the patient wasn't doing much better.<br /><br />In my rush to get home to take over care of my children from the babysitter, I neglected to chart my communications with the physician. (And somehow went an entire shift without charting vent settings!? Facepalm! WTF??)<br /><br />And the night shift nurse took exception to the hot mess I handed her and promptly tossed me under the bus.<br /><br />Fade to employee conference. I sat in my seat while my manager and educator talked down to me, asked me loaded questions in the most condescending tone they could muster, and basically held my nuts to fire...<br /><br />Because I screwed up and didn't document.<br /><br />So in the meantime, I've been banished to "the garden" to take care of chronic patients. <br /><br />There are so many things wrong with the way I was treated that even now I get tears of frustration thinking about it.<br /><br />BUT.<br /><br />Kids, remember this.<br /><br />If it isn't charted.<br /><br />It. Never. Happened.Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com3tag:blogger.com,1999:blog-9027498228520172257.post-8677489066770657912011-08-03T17:56:00.000-05:002011-08-03T17:56:00.116-05:00You Might Be...You might be a nurse if:<br /><br />You've signed a check with your name...and RN.Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com12tag:blogger.com,1999:blog-9027498228520172257.post-70721238099623585232011-07-29T19:19:00.000-05:002011-07-29T19:19:00.310-05:00You Might Be...You might be an ICU nurse if:<br /><br />Your measurement of time is "minutes until it's time to write vitals."Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com3tag:blogger.com,1999:blog-9027498228520172257.post-53615652786292004082011-07-26T07:40:00.000-05:002011-07-26T07:40:00.229-05:00I Just Don't KnowLately I've been contemplating the direction I'd like to take this blog. <br /><br />The longer this space exists, the chances of my true identity being unmasked grows, possibly exponentially. When I started this iteration of my blog, I had no idea that it would grow to be even as mildly popular as it has. I wasn't clear sighted enough to plan for that from the start. As a result this "anonymous" blog is hopelessly entangled with my "real" life. <br /><br />For instance, the master email Blogger associates with this account happens to be my gmail account that I use for *everything*. Not a big deal because that email address isn't used anywhere except for me to sign in. Nicely compartmentalized I thought. Only when somebody sends me a Google+ invite, suddenly my Picasa account (with all my blog pictures) will be linked to my uber-Facebook experience. And suddenly my real name will be substituted where my nicely anonymous username had reigned. Blast it.<br /><br />I can't say that it isn't tempting to exit the proverbial blogging closet, and just become a real person in both senses. But that would pretty much preclude any patient stories no matter how fabricated. And frankly, do I have enough important things to say regarding nursing that people will continue to visit without the sensationalism of my patient encounters? <br /><br />Am I ready to give up the sanctity of my virtual repository to unload and get things off my chest?<br /><br />I just don't know.<br /><br />At some point I'd like to transition my writing to more mainstream outlets. Does an anonymous body of work allow for that? <br /><br />"I'd send you examples of my writing...except I can't...you know patient privacy and all. I write real good though. I swear."<br /><br />I just don't know.Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com7tag:blogger.com,1999:blog-9027498228520172257.post-28038926154628925662011-07-24T19:13:00.001-05:002011-07-24T19:13:00.519-05:00A Different Kind Of CrazyAmongst my least favorite patients to care for are those that have lost their noodle. Be it dementia, ICU psychosis, mental illness, it just wears me out having to deal with them. <br /><br />I like logic. I like things to be orderly. I like it when people have been educated, and the information leads them to draw the conclusions I intend.<br /><br />Crazy people don't do that. And that cuts across the grain of everything that makes my purplish haze of a world tolerable.<br /><br />But I ran across a new kind of crazy this week at work.<br /><br />This lady, (let's call her Eleanor), was 100% with it. She was completely lucid, she truly was that ever elusive A&Ox4. This is quite an achievement considering she'd come in for a valve replacement over a month ago and ended up with a CABGx5 and a balloon pump. Following her surgery, she rode our carepath upstairs only to come crashing back down as an RRT in respiratory stress. <br /><br />It seems that the yahoo techs on our stepdown floor *still* cannot get it through their thick skulls that if a patient drinks too much water, with all the fluid shifts from being on pump, the patients drink themselves straight into pulmonary edema. Not to mention the atropine given pre-anesthesia makes *everyone* wickedly thirsty, for *days*. So when the techs get tired of answering call bells about drinks of water, they sure as heck will bring the patient a big huge pitcher of water and let them drink themselves into a gurglely, pink frothy mess.<br /><br />So it was with Eleanor.<br /><br />And she ended up re-intubated. Then extubated. Then re-intubated, and extubated yet again. If you've played this game before, you know that each subsequent re-intubation significantly reduces the chances of a favorable outcome. Counting her surgery, Eleanor is working on post-extubation #3. Even now after spending 8 hours each night on BiPAP, her PCO2 is routinely greater than 65 each morning.<br /><br />She's also failed her swallow study 3 times now.<br /> <br />All this to say that Eleanor is *strictly* NPO. <br /><br />She knows this. <br /><br />And she knows why.<br /><br />And she knows the consequences of noncompliance. <br /><br />But this does not stop her from asking, begging, pleading, groveling for a drink of water as many times an hour as you are willing to entertain. She actively tries to deceive anyone who comes near her bed and trick them into giving her water. She tries to split staff and family members and play them off one another to manipulate them into giving her water. <br /><br />Honestly I've been around better behaved toddlers. (Two of which happen to live with me.)<br /><br />Really I'm at a loss to adequately convey the sheer, colossal, unbelievable stupidity of it all.<br /><br />I performed impeccable oral care hourly to maintain her oral mucosa. But my reward for this above and beyond (unit policy and procedure is Q4)? Each swab is met with a greedy demand, "MORE!!" Upon refusal, she throws anything within reach on the floor in protest. Pillows. Blankets. Her Bairhugger nozzle. You wouldn't believe how low my bullshit tolerance for this kind of shenanigans is. <br /><br />Maybe a better, more saintly nurse would have had the patience to deal with these outbursts. Me, with my curmudgeonly tendencies, simply didn't give the items back to her the second time they ended up on the floor. When she started immediately sucking the water out of each swab (nearly aspirating on that small amount of water each time) rather than letting me wet her mucosa, I promptly switched to using chlorhexidine gluconate instead. Funny, she was much less enthusiastic about her oral care after that.<br /><br />On my second night taking care of her my frustration came to a head. My other patient, a fresh <a href="http://www.cts.usc.edu/zglossary-pericardialwindow.html">pericardial window</a> was starting to act pretty sick. He was bradying down into the low 40s, and I had no pacing access other than transcutaneous pads on the crash cart. His pressure was dropping from 160's systolic on 5 mcg/kg/min of nipride, to a systolic of 90-100 with the nipride on standby. <br /><br />In the middle of this, Eleanor started demanding water. Yelling, cussing, cajoling. Saying idiotic things like, "Just pour it on top of me, I don't even have to drink it. Just pour it all over me." When nobody was paying attention to her, and there were several of us in the room because of my other patient, she ripped her BiPAP mask off and threw it across the room.<br /><br />I'd had enough, and as I was putting her mask back on, I kind of lost it on her.<br /><br />"You need to *stop* this. You are a *grown woman*, you need to start acting like it. You are embarrassing yourself and your family by the way you are acting. My other patient is extremely sick right now, and instead of being able to help him like I should, I'm here, dealing with this foolishness."<br /><br />In a poetic cinematic world, she would have realized how silly she was being, become remarkably compliant, if not apologetic. Then she would have written letter to the administration about the incredible life-saving care she received, highlighting each of the nurses she had.<br /><br />In the real world, she pulled off the biggest 2-year-old pouty-lip I've ever seen. <br /><br />But at least she was quiet.Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com5tag:blogger.com,1999:blog-9027498228520172257.post-2371244796568155752011-07-22T09:17:00.000-05:002011-07-22T09:17:00.148-05:00You Might Be...You might be a nurse if:<br /><br />Before taking ibuprofen for body aches or headache, you automatically try to code the barcode for documentation...Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com4tag:blogger.com,1999:blog-9027498228520172257.post-47833783333931168272011-07-21T17:16:00.000-05:002011-07-21T17:16:00.266-05:0025 Best<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjEERW5CE6E0ZatXJMV-oZ0uPxgVQYyd-4jvIyvmrKZbvZe1DzdCBJ6HXhel3ujTyBG86wEN0fk0QjUPcqmOr4LTZ0Gxqo_p3G-76k1y5yAth7kH1GK0yEmjqIP-X1vu_6Lxm-PoTLdzxU/s1600/VoN-blog-award.png"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 126px; height: 127px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjEERW5CE6E0ZatXJMV-oZ0uPxgVQYyd-4jvIyvmrKZbvZe1DzdCBJ6HXhel3ujTyBG86wEN0fk0QjUPcqmOr4LTZ0Gxqo_p3G-76k1y5yAth7kH1GK0yEmjqIP-X1vu_6Lxm-PoTLdzxU/s200/VoN-blog-award.png" border="0" alt=""id="BLOGGER_PHOTO_ID_5631516138546043490" /></a><br />It seems nurseXY has been selected as among the 25 best nursing blogs by David Gurevich over at <a href="http://qiexamprep.com/best-nursing-blogs.php">QI Exam Prep.</a> <br /><br />Pretty heady company he's put me in with, I'm not sure I quite belong. However, I appreciate the recognition.<br /><br />Thanks David!Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com4tag:blogger.com,1999:blog-9027498228520172257.post-65636017530923077162011-07-20T12:45:00.005-05:002011-07-20T14:14:22.870-05:00P. R. N-competence.So I started working PRN at the ICU where I did my externship. I'll be working 4 shifts a month, which works out to one a week, but it's nice in that I don't have to work them that way, I can clump them if I like.<br /><br />It works well since the hospital is about 10 minutes from my house, as opposed to 45 minutes minimum to my other job. It also works well considering I have only 6 months experience, 3 1/2 months really if you look at my experience since coming off orientation. Most hospitals around here won't even glance at you until you have one year plus at least. My manager had to go to the CNO to get me approved. It's nice to have people willing to go to bat for you though.<br /><br />One thing I've learned quickly though in my short career thus far is that experience doesn't necessarily equal competence. This has been vividly illustrated to me a couple of times recently.<br /><br />This past week I sat through hospital and nursing orientation, (again) at my new job. Part of that orientation process involved a pair of EKG exams. The first of these exams was 15 questions long, but only the 4 lethal rhythms held any point value--25 points each. The other 11 questions weren't worth any points--information not announced to us, but readily available because the computer displayed point values for each question during the exam. The lethals were not difficult. Predictably there were strips showing asystole, v-fib, and a couple v-tach (one even a torsades, but that wasn't even an option to be picked.) Not rocket science, not tricky.<br /><br />The nurse next to me there in orientation had been quite vocal about her 1 1/2 years of big-time experience at an ED in a medium-size town about an hour away from our metro area. She unfortunately failed the lethal EKG exam. Studied for 30 minutes, and promptly failed it again. Now she has to complete an EKG/Dysrhythmia course, just to keep her job.<br /><br />Secondly, my wife is currently precepting at work. Her intern is a nurse with 18 months experience up on the floor and transferred into the PICU. But this nurse lacks basic skills like passing meds on time. She's been sent to a couple codes, only to stand around and watch. Even tasks such as recording vitals appears to be beyond her skill-set. In fact, it seems what she's demonstrated she's best at is letting the PICU nurses know, "That's not how we do it on the floor..." The scariest part of this situation is that she's already started her acute-care nurse practitioner program--online of course.<br /><br />So on behalf of all us with less than that magic bullet of one year's experience... I rattle convention's cage!Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com7tag:blogger.com,1999:blog-9027498228520172257.post-36525099981124307492011-07-18T20:16:00.002-05:002011-07-18T20:25:44.195-05:00You Might Be...You might be a nurse if:<br /><br />When using the restroom you automatically reach for gloves before wiping...Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com6tag:blogger.com,1999:blog-9027498228520172257.post-6261775259346845922011-07-07T22:05:00.006-05:002011-07-08T05:07:00.569-05:00Up In The AirLife is up in the air right now. <br /><br />I have no real focus, and I'm really unsure what direction to proceed.<br /><br />My original plan was painfully simple. Go to nursing school. (Check.) Graduate and get a job on the biggest, baddest ICU around. (Check.) In two or three years apply for CRNA school and get on with life. (.....)<br /><br />Muddying circumstance #1: <br /><br />This lovely president of ours, Obama, enacted legislation that dictates those that make 10 years of payments on their federal student loans while working in a public service capacity, will have the remaining balance of their federal student loans forgiven. RN's definitely qualify as long as they work for a not-for-profit organization, which I currently do. Interesting tidbit: Nurse Practitioner's qualify, CRNA's do not. After doing the math, this loan forgiveness could total as much as $200,000 in my case... Market analysis of compensation for NPs shows that the gap between CRNAs and NPs is starting to narrow. In short NPs may soon be making the kind of salary reserved previously for CRNAs. <br /><br />Now consider that the cost of the CRNA schools in my metro area both top $75,000, while NP school falls under the category of regular graduate school. CRNA students are prohibited from working during school (in fact both schools here will kick you out of the program, no questions asked, if they catch you working.) NP students at local schools do not have any such restrictions. And here's the kicker--the tuition reimbursement program at my current hospital *almost* covers the tuition for graduate school. They also have a TDA (Two Day Alternative) program where employees work Saturday-Sunday every week--two shifts, but keep full time status and benefits, and earn an extra differential that approximates working three shifts instead of two--that would allow me to go to school full time during the week.<br /><br />The nursing school I graduated from has an Acute Care Nurse Practitioner program...<br /><br />Thinks that make you go hmmm.<br /><br />Muddying circumstance #2:<br /><br />My wife and I have been fortunate enough to have her younger sister living with us to watch our kids while both of us work night shift. This allows us to work as many shifts together as possible, allowing us to have days off together. However, that situation will be changing. I'll spare you all the drama and gnashing of teeth, but rest assured it hasn't been a pleasant situation with frustrations ranging from not being available when we were counting on her, to wondering about our kids safety while in her care. <br /><br />The nice thing about working as nurses is that we only work 3 days a week, so it *can* be done not needing childcare at all. But that means that we will only have one day a week off together, and really because of the logistics of night shift, it means that we'll have two half days off rather than a full day. <br /><br />We are exploring options that include me moving to day shift to cut down on the daycare needs, but that also requires me transferring to another hospital within the system since my wife and I work on opposite ends of the city currently. And that means leaving my beloved CVICU...<br /><br />Muddying circumstance #3:<br /><br />I have been dying to get out of this town since I got here (state, really). The summer heat/humidity kills me. I crave seasons. I crave snow. I crave being able to spend time outdoors without melting into a puddle on the blistering concrete or triple digit asphalt.<br /><br />I began researching grad schools in other parts of the country, and have been very, very attracted to Duke. I love the idea of a big name school. I love that the hospital is next door to the school. I love that the hospital has a program for employees that pays up to 90% of your schooling in exchange for contract on graduation... I love the idea of North Carolina, where the average high temperature in the summer tops out in the low 90s... I love that North Carolina is a <a href="https://www.ncsbn.org/nlc.htm">Nurse Licensure Compact</a> state... I love that Duke has one of the few Pediatric Acute Care Nurse Practitioner programs in the country...<br /><br />Aauugggh! My brain hurts!Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com15tag:blogger.com,1999:blog-9027498228520172257.post-90266949135587173932011-06-28T09:06:00.000-05:002011-06-28T09:06:00.120-05:00By Faith, Not By SightA large man by anyone's standard, he was much more than overweight. He was tall and heavily framed, with a broad face and meaty hands. Still though, he carried probably close to 75 lbs extra with him wherever he wandered. By all accounts this mountain of a man was immovable, unconquerable, invincible.<br /><br />That is, until he went to the dentist.<br /><br />It was a simple extraction, nothing so involved as a root canal or other oral surgery. And it took no more than 15 minutes from needlestick to lollipop unwrapped from the cheery mug on the counter, meant to soften the blow of paying for often painful services at the payment window.<br /><br />Even as he lumbered out the door, pausing to hold it open for a harried mother with three small children in tow, he had no idea.<br /><br />He had no idea he was already dead.<br /><br />A few weeks later, he had been ill for more than a week. He passed it off as being fatigued from the busy season at work, but his wife knew better. That was his way though, shrugging off illness like a bull swatting a horde of biting flies with his tail. But when he began talking out of his head, making incomprehensible requests and becoming severely agitated when she couldn't make heads or tails of it at all, she ran for her cell phone to call 911. Likely that saved her from injury as well, for as soon as she left he had gathered himself unsteadily to his feet and promptly collapsed onto the oak and stained glass coffee table, flattening it and sending shattered leaded glass whistling through the air like so many pieces of brightly colored shrapnel.<br /><br />Arrival at the ED found him in dire straights indeed. The 12 lead EKG in the ambulance on the way in showed massive ST elevation, but his clear stroke-like symptoms described by his wife were also particularly troubling. The monitors barely registered a blood pressure. The impressive array of superficial cuts from the coffee table that seeped and oozed blood were by far and away the most visible sign of trouble, but were the least concerning. At least until the removal of the particularly large fragment in the middle of his chest began bubbling black purulent blood like black gold oil flowing out of the ground in West Texas.<br /><br />The final tally of CT's and other tests read like a cheap Saturday night horror flick. An abscess in the sternum had carved out its own living quarters, eroding into the aortic arch and front face of the heart. This did little more than expose the massive biological vegetation growing throughout both ventricles and atria.<br /><br />Clearly a large fragment of this vegetation is what caused the massive stroke that strangled the life from half of the cerebellum, and most of the occipital, temporal, and frontal lobes on the left side of the brain. Unmercifully the mid brain and brainstem were spared, allowing bodily function to continue. And just to make life interesting, he was in massive septic shock, which had taken out most of his gut and kidneys.<br /><br />A semi truck would have caused less damage.<br /><br />And that's how I met him--recovering him from the 16 hour surgery to replace his aortic arch and bypass the 5 coronary artery blockages, and to reconstruct as much of his mediastinum as possible. He was on the ventilator, IABP, CVVHD. He was maxed on 4 different pressors, barely maintaining a MAP greater than 50. Chest tubes sprouted from every possible sector of his chest, draining foul black sludge from his tortured body. His urine, less than 20 mls of it per 12 hour shift, was black as well. <br /><br />No other hospital in our area would have done this operation.<br /><br />And through it all his beautiful family persevered. Stealing 5 minutes at a time during lulls of activity to pray over him, and gracefully stepping back to allow us to continue our care. Remaining sweet and grateful, thanking each nurse, each physician for caring for him as they left his bedside. Speaking words of encouragement to the other three patients and their families in the pod (none of which nearly as ill as their own loved one). Undeniable, unbridled, impossible faith.<br /><br />I found myself in a moral dilemma. Every ounce of my medical knowledge told me that this man would not, could not survive. This knowledge demands of my ethical standards to keep my patient's family informed, albeit with caring and sensitivity, but a *realistic* picture. I simply could not live with myself if I created a false sense of hope for someone.<br /><br />But this family's faith is contagious. Do I dare hope against glimmer of hope that a miracle happens? Is it my duty to battle this unrealistic shred of sanguineness?<br /><br />I carefully, lovingly even, kept the family up to date regarding his condition. I could tell they were firmly grounded. They knew and understood the severity of his condition.<br /><br />After one such update to his wife, I found myself apologizing to her for not being able to fix him for her. <br /><br />Resting her hand momentarily on my arm, her tired eyes sought mine and smiled a quiet, knowing smile. <br /><br />"Right now," she said, "We're walking by faith, not by sight."Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com8tag:blogger.com,1999:blog-9027498228520172257.post-15659459466418809652011-06-22T15:01:00.003-05:002011-06-22T15:37:57.252-05:00Re-EmergencePerhaps it's just been a break to catch my breath. Perhaps memorializing everything in black & white electrons here on this blog meant I had to sort through and deal with everything that's been going on--which I just didn't want to do. Perhaps I've just been lazy. <br /><br />I don't know.<br /><br />But here I am, first post in nearly a month. I'm not sure where to begin, but I'll try.<br /><br />In short, my depression came raging back, despite the SSRI I've been taking. I'm fairly certain it's probably because I just quit running cold turkey. My trip to the Grand Canyon (although a life altering experience) injured my knee making it very difficult to run without pain. Add the insane schedule of my internship, and the thought of a painful gym session was much less than appetizing. Or maybe depression just does that--returns without invitation to steal away joy for no reason at all, to just laugh its evil giggle while I foundered and gasped and struggled.<br /><br />Regardless the reason, I slipped again into the deep, dark pit of loathing. My wife disengaged because it's easier to get wrapped up in kids and work than deal with an embittered bastard of a husband cloaked in the throes of desolation. My kids were driving me up the wall. Church ceased to salve my soul. My friends disappeared because I was always working or sleeping. Work sucked, but amazingly it just sucked the same amount and actually became relatively tolerable.<br /><br />The breaking point came the night that I had an extremely vivid dream where I awakened in an unknown place. By the time I pieced things together I realized I had been committed to a mental health facility. As I lay there trying in vain to orient myself, mind befuddled in a medication hangover, my wife appeared in the doorway. <br /><br />Cheerily she said, "Oh great! Look who's awake!" <br /><br />My relief in seeing a friendly face was quickly replaced with abject horror over the realization she was there as an employee, not as a wife. She actually worked on the unit.<br /><br />I was then accused of sleeping with my "hands under the blanket, again", with a knowing shake of the head. She left the room as I lay there trying to understand what that could possibly mean, why it was bad, and how I could prevent myself from putting my hands under the blanket while I slept...<br /><br />I followed her from my room into the large common area to discover her sitting at a table with the other nurses, chattering away and laughing at some unheard story of levity.<br /><br />The dream was wrong in so many ways, and couldn't happen in real life, but I cannot even begin to express the vividness of the dream or the feeling of betrayal...<br /><br />Regardless it galvanized me to action, and I began taking double the dose of my SSRI, and now a couple weeks later, things seem to be smoothing out a bit. I'm not sure what I'm going to do when my 3 month supply is gone in a few weeks rather than a few months. <br /><br />I need to return to exercising, but I'm finding it difficult to force myself. <br /><br />Anyway, I'm back. Thanks for all the concern. I hope the next post won't be quite so long in the making.Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com14tag:blogger.com,1999:blog-9027498228520172257.post-45347678188059101272011-05-28T07:53:00.001-05:002011-05-28T07:54:14.669-05:00Missing In ActionI'm still here. I think.<br /><br />Work has been mostly ok.<br /><br />Everything else has been a little rough.Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com7tag:blogger.com,1999:blog-9027498228520172257.post-9307624021505588192011-05-04T09:23:00.005-05:002011-05-04T09:56:17.488-05:00Bathos[bey-thos, -thaws, -thohs]–noun, 1.) a ludicrous descent from the exalted or lofty to the commonplace; anticlimax. <br /><br />Throughout my internship I was often given the most difficult patients on the unit. And as I blossomed from a fragile seedling root-bound in a plastic sprouting tray to a plant hardy enough for transplant, my preceptors stepped further and further back, allowing me to manage my patients, my way, developing my practice. At the end I was virtually on my own as my preceptors often were called to fulfill other functions on the unit.<br /><br />And I did well. I managed some truly tough assignments, and my patients were the better for my care. I admitted countless CABG's. And those turned into redo CABG's, or extremely sick CABG's. And then it was IABPs, and LVADs, and impellas, culminating with admitting heart transplants and double lung transplants. On my own.<br /><br />My unit and my internship experience turned out to be everything it was advertised to be. I was excited when I came off orientation to be on my own, ready to save the world. Or at least whatever train-wreck heart surgery came out of the OR suite that day.<br /><br />Our unit is very busy right now, and higher acuity patients than usual. Right now we have 2 double lungs, 2 heart transplants, 2 LVADs, and an impella. One of the heart transplants went on ECMO yesterday, and there is another heart transplant, and lung transplant scheduled for today. This is on top of the run of the mill CABGs. 21 beds, 21 patients.<br /><br />With all this glorious acuity, for the past 3 nights I've been assigned...<br /><br />**drumroll please**<br /><br />A blind VAT with cancer, on the unit for 33 days because he has a creatinine of 7.5 while making copious urine, pneumonia that won't heal, and he can't hold his sats above 85% without a venti <span style="font-style:italic;">and</span> nasal cannula. <br /><br />And a recent stroke victim who had an AVR and came down with a serious case of pump-head. He's so unpleasantly confused he's pulled nearly every tube and line possible, <span style="font-style:italic;">while restrained.</span> He's been on the unit for almost 3 weeks now.<br /><br />And for the 3 weeks I've been off orientation? Exactly the same kind of patients, night after night.<br /><br />Grind your soul into the asphalt slightly-too-sick-for-the-floor confused med-surg patients. EXACTLY the kind of patients I busted my ass to get hired into a high acuity unit to AVOID.<br /><br />I get that I'm new. I do. I really, really do.<br /><br />But come ON.Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com7tag:blogger.com,1999:blog-9027498228520172257.post-72290706011882010642011-04-29T22:25:00.009-05:002011-04-29T22:45:46.582-05:00Ok, Ok, I Want To Be Popular......so please vote for me.<br /><br />I got sucked in. <a href="http://www.fibers.com">Fibers.com</a> is hosting a T-shirt design <a href="http://www.fibers.com/contests/nurses-week-2011">contest for Nurses Week</a>. There are prizes, and of course in exchange, you fork over your intellectual property allowing them to market your T-shirt idea and profit from your creativity. But, it's kind of fun designing them and I highly doubt I'd get rich from the T-shirt business anyway.<br /><br />Anyway, here's my designs, please go vote for me:<br /><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTVOxgZ6ZbMjNV_gBt7v0-AQ74n0voDbcUfyAfosqgCNSUiAVDnbwMmuFndpAdSWU81aLPzdUfE9k2rUHfQgb_7X36S0mAQPqXIGUgyBOYyUHFAT8hVLi16NsgBx7cTwcuvJNY2iVyb7E/s1600/poop.jpg"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 400px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTVOxgZ6ZbMjNV_gBt7v0-AQ74n0voDbcUfyAfosqgCNSUiAVDnbwMmuFndpAdSWU81aLPzdUfE9k2rUHfQgb_7X36S0mAQPqXIGUgyBOYyUHFAT8hVLi16NsgBx7cTwcuvJNY2iVyb7E/s400/poop.jpg" border="0" alt=""id="BLOGGER_PHOTO_ID_5601216888099609074" /></a><br /><a href="http://www.fibers.com/contests/nurses-week-2011/nursing-poop-poseurs.D41864">Vote for Nursing Poop Poseurs Here.</a><br /><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjeXcNZskeyRjGSszXmK1lmaCUKmylFbav_jvm-H6lsXsjLmFv4CMbCqLTZKD1zAX3DU-m66k_AmlsY7P86aSinLIpl6_QgQ36McRDKsZRjneFrIm0BJwZR0Oh80u7snlpUT2aMPzS6Lbs/s1600/butts.jpg"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 400px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjeXcNZskeyRjGSszXmK1lmaCUKmylFbav_jvm-H6lsXsjLmFv4CMbCqLTZKD1zAX3DU-m66k_AmlsY7P86aSinLIpl6_QgQ36McRDKsZRjneFrIm0BJwZR0Oh80u7snlpUT2aMPzS6Lbs/s400/butts.jpg" border="0" alt=""id="BLOGGER_PHOTO_ID_5601216890437765026" /></a><br /><a href="http://www.fibers.com/contests/nurses-week-2011/nurses-saving-butts.D41863">Vote for Nurses Saving Butts Here.</a><br /><br />And one for the guys here:<br /><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiKZA9j0t-D4cAOd1yvOY0fevHh5HwWbquKvXxuwsrn-tdEfU8Zhf87jmiWVYhAxpiKngFWIBIj-1P7wgRlGee_JPXdnb6xNoxMru6sMFWG-1sjqCKX_7JuK9YV0QvUcIPNiYvTsYP6cVA/s1600/RN-BSN-XY.jpg"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 400px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiKZA9j0t-D4cAOd1yvOY0fevHh5HwWbquKvXxuwsrn-tdEfU8Zhf87jmiWVYhAxpiKngFWIBIj-1P7wgRlGee_JPXdnb6xNoxMru6sMFWG-1sjqCKX_7JuK9YV0QvUcIPNiYvTsYP6cVA/s400/RN-BSN-XY.jpg" border="0" alt=""id="BLOGGER_PHOTO_ID_5601216890935467106" /></a><br /><a href="http://www.fibers.com/contests/nurses-week-2011/rn-bsn-xy.D41857">Vote for RN-BSN-XY Here.</a><br /><br />While you're there, design your own. It really is kind of fun.Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com6tag:blogger.com,1999:blog-9027498228520172257.post-90941092159986586512011-04-29T09:24:00.000-05:002011-04-29T09:24:00.618-05:00Brought To You By The Letter, "Oh $#1T!"I learned something new last night. <br /><br />You know what sounds like rain gently thrumming on the soft top of a Jeep?<br /><br />Well, it turns out that blood spurting and spattering onto acoustic ceiling tiles makes almost exactly the same sound. Eerie really.<br /><br />And that folks, is what happens when a patient pulls his IABP out of his femoral artery.<br /><br />I learned something else last night too.<br /><br />You know what sounds like a dropping a watermelon on concrete?<br /><br />Well, it turns out that a fainting coworker's head smacking the floor sounds remarkably similar.<br /><br />And that folks, is what happens when your pod partner faints when she sees blood spurting from her patients femoral artery after he pulls out his IABP.<br /><br />Lucky for me I was already gloved up about to draw labs on one of my patients when I heard the aforementioned, very liquid sound followed closely by the monitor and IABP machine alarming. The other aforementioned sound rounded out the trio.<br /><br />On a dead sprint to the other side of the room I managed to scatter the bucket of bed bath supplies for the sake of grabbing a towel, all the while yelling my head off for help. <br /><br />The patient, all 6'5", 148kg of straight-up-pissed-off was thrashing around in the bed. He was intubated, and supposedly sedated on 60 mcg/kg/min of propofol (which is a 100 ml bottle every <span style="font-style:italic;">90 minutes</span>!). He apparently took exception to, well, hemostasis I guess.<br /><br />I clamped the towel down on his fem site, then got control of his right wrist and pinned it to the bed. Next I stuck the elbow of my arm holding pressure deep into his quad and got him to straighten his leg. Lucky for me his other arm got tangled up in his vent circuit and I was able to should block his other knee or there's a good possibility I'd be wearing a black eye today, or worse.<br /><br />By this time help was arriving, the crash cart got yanked open, the patient is in v-tach (as best we could tell), and was being restrained forcibly by 3 other people. The CRNA on call rolls in (their sleeping rooms are right outside our unit). He takes one look, calls for a vial of vecuronium and paralyzes the patient on the spot. The secretary is running for blood and a rapid infuser from the trauma ICU, there's a saline bolus running in wide open. Somebody shoots an index, it's like 0.9, but the dude somehow still has a pulse. His pressure is in the toilet, and although he converts out of v-tach with some epi, he still has ectopy all over the place. Someone was nice enough to set up a c-clamp because my arms are burning from holding that much pressure on the site (I may or may not have been trying to single handedly push his hip through the bed.)<br /><br />Meanwhile a code purple has been called for my coworker and she gets C-collared and whisked off to CT on the way to the ED. <br /><br />There was eleventy-billion people in the room, including family from the other 3 patients in the pod. They couldn't get out because there were so many people attending to the patient and my coworker. It was more chaotic than any code I've been to yet.<br /><br />Surgeon arrives on unit, and he's pissed. He wants somebody's head on a platter, and since my co-worker cracked hers on the floor, I'm next in line. He literally wants someone fired. My night charge nurse steps up to the plate, and sets the surgeon straight--for which I'm truly, truly grateful. <br /><br />"That nurse and his quick thinking is the very reason your patient is still alive!"<br /><br />We did, in fact, get the patient stabilized. He's only slightly more sick than he was before the incident, and that is a very lucky thing. It could have easily been much worse.<br /><br />I'm sure there will be all kinds of legal shenanigans and ass-covering in the days to come, but it was enough for one night.<br /><br />In fact, I hope I never see that again!Roberthttp://www.blogger.com/profile/00243748655669695310noreply@blogger.com11