ACLS Drama

Because of our patient population, unit policy states that to travel with a patient (to radiology, dialysis, or even transferring to the step down unit), the nurse accompanying the patient must be ACLS certified.

Hospital policy states that new-hires must become ACLS certified within 12 months of hire.

Obviously, waiting 12 months to take ACLS isn't really an option on our unit, since a good deal of our patients travel, and not being able to accompany them becomes a logistical staffing nightmare. And that's not even considering the sheer number of codes we see... Therefore, our educator and manager both "strongly encouraged" us to take ACLS before the end of our internship so that we'd be certified when we come off orientation.

My fellow interns and I sit on the front row during the classroom portion of the internship. The classes are combined with all med-surg, tele, and ICU interns, and that's what our unit does--"we're the best of the best, and we act that way." Or so we were "strongly encouraged" to portray by our manager and educator. One day as the internship class broke for lunch, my fellow interns and I discussed heading over to the unit to pick up the books for our Saturday ACLS class so we could take the pretest.

And thus started the ACLS Drama.

The class instructor overheard us, (a conversation she was not part of,) and flipped out.

"You haven't had the entire EKG interpretation internship course yet. We haven't talked about any of the ventricular arrhythmias. We haven't introduced the blocks yet. You won't even understand what they're talking about in the ACLS course, so it's pointless for you to even go right now!"

As insulting as this was ("You're too stupid to take the course!"), I have turned over a new leaf, and I let it roll off my back, shrugged my shoulders, and said, "We're just doing what our manager and educator told us to do."

So the class instructor called our manager to gripe. And she called our educator to gripe. And then she called the ACLS instructor and told her that we'd signed up and couldn't possibly be ready for such an advanced course.

All around us the political (and hormonal I suspect) firestorm raged, but our manager directed us to take the course regardless.

Meanwhile, I had an entire semester of critical care in nursing school that incorporated EKG interpretation throughout. I also had a year's ICU experience where rhythm identification was a daily part of my job. I know what a heart block looks like first degree, third degree, even both types of second degree. I know enough to say, "Oh S#&%!" when the monitor screen fills up with v-fib squigglys or v-tach scribbles. Hell, I even know that a nice pretty rhythm is useless without an accompanying pulse.

But I digress.

When I showed up on Saturday morning for ACLS (with pretest with passing score in hand), we quickly sailed through the BLS portion of the course and then split into renewals and first time certifications. There were only 5 of us first timers--the 3 of us from our unit, and then a nurse with 4 months experience and a nurse with >20 years of experience that had let her certification lapse. As soon as we were separated out, the instructor starts in on a tirade of how those of us in the internship, "with so little experience," weren't going to reap the full benefit of the class, etc, etc, ad nauseam.

I'd had enough.

And so I went all nurseXY on her.

"I guess I'm confused. Do we need to sign up for another class? Are we not allowed to take this class?"

"Well, no, I can't keep you from taking the class."

"Then why are we still discussing this? And when will we move on to the course content?"

Not particularly diplomatic, I know. Rude? Quite possibly.

But SHEESH!!

And so we began. As we moved into the content it was immediately clear she was singling us out with questions, trying to trip us up and make us feel inadequate or unprepared. What she didn't realize was how hard we had been pushed to learn drugs used daily on our unit, most of which are code drugs. She didn't realize the amount of physiologic and pathological knowledge required to get through a single shift on our unit. She didn't realize that we had to truly understand our patients disease processes to even begin managing them.

Everything she threw at us, we had a ready answer for. It was downright inspiring--you could hear the triumphantly rowdy underdog music swelling in the background. And then we caught her in a mistake.

In the end, after all the fuss, in our "but this is the way we do things" face-off, she was the one who blinked first.

As the day moved on into the megacode and we took turns at each position, it was quickly apparent that the other two nurses were actually the weak links.

For example, the one with 4 months of tele experience couldn't wrap her head around the concept of PEA--interestingly enough exactly how much experience our class instructor told us we needed to have to fully understand the intricate subtleties of ACLS. The other, the one with >20 years of experience kept mixing up atropine and amiodarone, and forgetting to defib the patient when appropriate.

One of my fellow interns summed up the day perfectly: "And it was us she was worried about?!?"

Today in class, more than 3 weeks later, we finally went over the heart blocks and ventricular arrhythmias. And wouldn't you know it the whole inappropriately early ACLS class came up again! And then we were politely asked to stop answering questions during the lecture and let others have a chance as we learned about hospital SDMOs on cardiac resuscitation, which oddly enough mirror ACLS.

Ugh. I hate drama.

Honor, Truth, Trust

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.

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.

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.

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.

• 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.

My new active lifestyle meant having time for:

• 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.

Alas, it's not to be. At least not yet. Maybe it will ease when I come off orientation.

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.

When Patients Refuse to be Discharged

My unit's mortality and morbidity stats suck.

But there's a reason for that, and it's no reflection on the quality of care or the competence of the staff. We take the sickest of the sick. We take the cases that nobody else will even consider. We're the dumping grounds for the private vascular hospitals in the area when things go wrong so their stats don't take the hit. There's a reason why the vascular specialty hospital across the street has some of the best M&M stats in the entire country.

When you look beyond the stats and put faces to the numbers, this translates into a good number of patients who die on our unit. And it would seem that some of those expired patients aren't ever truly discharged, if you catch what I mean...

Even if you don't believe in ghosts, it's hard to dismiss the fact that our hospital is well over a hundred years old and in that period of time, there has been one emotionally charged situation after another playing itself out within our walls on a regular basis. It would be difficult to pass off that amount of energy in such a small space without entertaining the idea that something, or someone, could end up staying behind. And there is no other unit in the hospital that sees more of this intense type of action than ours.

In short, our unit is haunted.

Every unit has that one or two beds that seem to have more than their share of deaths because highly critical or terminal patients are repeatedly assigned there. It may be because of specialized equipment available in that room, or proximity to the nurses station. It may be that it's a single bed room allowing for privacy for families to say goodbye, or a larger room that fits more pumps/machines for highly critical care.

For us, that bed is Bed 18.

Now keep in mind that the two incidents I'm about to tell you happened first hand to people that still work on the unit today. These aren't spooky campfire ghost stories handed down through the generations like some Greek mythological legend.

On our unit we don't have call lights (thank heavens!) due to the fact that there is never not at least one nurse present in any room at any given time. To communicate with each other, we use an overhead intercom system. Occasionally on night shift, if there is low enough census, several nurses have reported an unknown, but weak female's voice coming on the intercom asking for help in Bed 18, when there is no patient assigned to the room. It's happened on nights where every staff member was male...

And then...

One night shift, two nurses walked into Bed 18 to set it up for a highly critical patient coming out of surgery (heart & double lung transplant). The bed was currently unoccupied, but had a long term patient (months on the unit) expire earlier that day. When the nurses were prepping the EKG leads--attaching new pads--they noticed there was a rhythm reading on the monitor. Thinking it was another patient from another bed pulled up on that particular monitor, they tried to reset the monitor to the current bed, only to discover that it was indeed set for Bed 18. To verify, one of the nurses jiggled the EKG leads, and sure enough a corresponding artifact generated on the screen. As they watched, the rhythm deteriorated into an agonal rhythm, and then to asystole...

There are nurses on night shift that refuse to be in Bed 18 by themselves to this day...