Just added the "MyTube" widget - now allows me to share YouTube videos. Scroll down and give it a whirl (like the Stairway to Heaven cover).
Need to work on customizing it (the white area makes the blessed thing look "patchy", no?)
"Ooohs" and "Aaahs" welcome ;-)
Thursday, August 30, 2007
Saturday, August 25, 2007
Truth is often stranger than fiction
A 27-year-old lady presented with persistent cough, sputum and fever for the preceding six months. Inspite of trials with antibiotics and anti-tuberculosis treatment for the preceeding four months, her symptoms did not improve. A subsequent chest radiograph showed non-homogeneous collapse-consolidation of right upper lobe. Videobronchoscopy revealed an inverted bag like structure in right upper lobe bronchus and rigid bronchoscopic removal with biopsy forceps confirmed the presence of a condom. Detailed retrospective history also confirmed accidental inhalation of the condom during fellatio.I ain't makin' it up...
I don't think I'll be able to keep a straight face the next time someone says "suction"...
"Vick's" Chew Toy
"Vick's" chew toy for your doggie dearest.Get 'em while supplies last?
Natch...
Wonder how long it'll take before the lawsuits start flying...
Wednesday, August 22, 2007
Professional Nurse? Or "trained monkey" ?
My appy-pologies to MonkeyGirl. I simply use her moniker because it is an apt 'term' pertaining to the situation.
New rules at my hospital following JCAHO recommendations: If a PRN medication is ordered in a specified range (dosage or strength), it is not ok to administer a dosage less than what has been ordered.
For example: I have an order for: Morphine 3-5 mg IV every 2-3 hours for pain.
Now not only am I not allowed to exercise critical thinking and nursing judgment by figuring out how much medication my patient needs, I am also supposed to automatically interpret that medication order to read: "Morphine 3-5 mg IV every 2 hours for pain".
"So what, Spook?" you say. "It follows The Joint Commission (cue reverential music) recommendations on the very subject. In fact that med order that you gave as an example is cited by The Joint Commission (cue reverential music) as something to be avoided - you can see their recommendations here. Your organization is just following recommended policy".
So, if someone is ordered 6 mg Morphine IM for pain, I can't exercise my critical thinking skills and administer 4 mg because the patient may not need 6 mg (or maybe because 6 mg would be an unsafe dose. More on this later). Instead, I'm supposed to call the physician and request s/he lower the dose.
All medications carry side effects - why administer more than that which is required? Don't get me wrong, I don't think patients should sit around suffering in pain (not only is it inhumane, but constant pain slows down the recovery process). But to dose them 6 mg when 4 mg work just fine is just plain stupid.
"But Spook, you can always call the physician and have the dose lowered. Aren't you bothered with medication safety?"
Well, yes, I could call the physician. And it works fine for a couple hours. What if the patient starts reporting increased pain? Now I have to call again to get the dose increased! This seems fine and dandy on paper - but it's a fools errand in real life. I am yet to find a nurse in the trenches who agrees with this approach and implementation.
"But Spook, that's why they have dosing ranges".
Right and wrong. Dosing ranges exist - but no longer do we have (say for example) 'Morphine 4-8 mg IV'. Ranges are now supposed to be much narrower along the lines of 'Morphine 4-5 mg' or some such. I welcome folks to handle a single post-op patient on my floor with such narrow dosage strengths...
Remember earlier on in this post where I mentioned the fact that a patient may not need the dosage ordered? I once had an anesthesiologist order "6 mg Dilaudid IV push now and repeat in 10 minutes" .... for an 86 year old female with a hip replacement with a respiratory rate of 16. I repeated the order four times to clarify - and each time he was adamant it was right.
Needless to say, I didn't carry out the order. I exercised clinical judgment and gave the patient a bolus of Dilaudid 0.5 mg and it helped her immensely. Patient reported good pain relief and was resting comfortably within 30 minutes. I documented the hell out of that incident and also placed and incident report - and made sure the floor Director knew what happened.
Now technically, according to JCAHO - I'm not supposed to do that. I'm not supposed to administer less than the dosage ordered. While it's easily obvious in this situation as to why I shouldn't have followed recommendations; I use this example just to point out that a lot of times, it is not as clear cut in black or white. Precisely why Nurses are taught critical thinking and are allowed to exercise clinical judgment.
Ladies and Gents, unless I'm missing the big picture somewhere - all this new intrusion by The Joint Commission (cue reverential music) is simply eroding my authority as a trained medical professional. If I can't be trusted to exercise my judgment in determining the appropriate intervention and medication dosage for my patient - what the hell am I there for?
Might as well replace us with trained monkeys and be done with the whole deal.
And speaking of JCAHO, I have another post/rant lined up about it...
New rules at my hospital following JCAHO recommendations: If a PRN medication is ordered in a specified range (dosage or strength), it is not ok to administer a dosage less than what has been ordered.
For example: I have an order for: Morphine 3-5 mg IV every 2-3 hours for pain.
Now not only am I not allowed to exercise critical thinking and nursing judgment by figuring out how much medication my patient needs, I am also supposed to automatically interpret that medication order to read: "Morphine 3-5 mg IV every 2 hours for pain".
"So what, Spook?" you say. "It follows The Joint Commission (cue reverential music) recommendations on the very subject. In fact that med order that you gave as an example is cited by The Joint Commission (cue reverential music) as something to be avoided - you can see their recommendations here. Your organization is just following recommended policy".
So, if someone is ordered 6 mg Morphine IM for pain, I can't exercise my critical thinking skills and administer 4 mg because the patient may not need 6 mg (or maybe because 6 mg would be an unsafe dose. More on this later). Instead, I'm supposed to call the physician and request s/he lower the dose.
All medications carry side effects - why administer more than that which is required? Don't get me wrong, I don't think patients should sit around suffering in pain (not only is it inhumane, but constant pain slows down the recovery process). But to dose them 6 mg when 4 mg work just fine is just plain stupid.
"But Spook, you can always call the physician and have the dose lowered. Aren't you bothered with medication safety?"
Well, yes, I could call the physician. And it works fine for a couple hours. What if the patient starts reporting increased pain? Now I have to call again to get the dose increased! This seems fine and dandy on paper - but it's a fools errand in real life. I am yet to find a nurse in the trenches who agrees with this approach and implementation.
"But Spook, that's why they have dosing ranges".
Right and wrong. Dosing ranges exist - but no longer do we have (say for example) 'Morphine 4-8 mg IV'. Ranges are now supposed to be much narrower along the lines of 'Morphine 4-5 mg' or some such. I welcome folks to handle a single post-op patient on my floor with such narrow dosage strengths...
Remember earlier on in this post where I mentioned the fact that a patient may not need the dosage ordered? I once had an anesthesiologist order "6 mg Dilaudid IV push now and repeat in 10 minutes" .... for an 86 year old female with a hip replacement with a respiratory rate of 16. I repeated the order four times to clarify - and each time he was adamant it was right.
Needless to say, I didn't carry out the order. I exercised clinical judgment and gave the patient a bolus of Dilaudid 0.5 mg and it helped her immensely. Patient reported good pain relief and was resting comfortably within 30 minutes. I documented the hell out of that incident and also placed and incident report - and made sure the floor Director knew what happened.
Now technically, according to JCAHO - I'm not supposed to do that. I'm not supposed to administer less than the dosage ordered. While it's easily obvious in this situation as to why I shouldn't have followed recommendations; I use this example just to point out that a lot of times, it is not as clear cut in black or white. Precisely why Nurses are taught critical thinking and are allowed to exercise clinical judgment.
Ladies and Gents, unless I'm missing the big picture somewhere - all this new intrusion by The Joint Commission (cue reverential music) is simply eroding my authority as a trained medical professional. If I can't be trusted to exercise my judgment in determining the appropriate intervention and medication dosage for my patient - what the hell am I there for?
Might as well replace us with trained monkeys and be done with the whole deal.
And speaking of JCAHO, I have another post/rant lined up about it...
Friday, August 17, 2007
The LawDog Files: This is exactly what I'm talking about ...
Stopped by the The LawDog Files and picked up that little beaut of a story.
I'll file that under my ever thickening folder titled "Federal Gummint cockups!"
Hat tip to Lawdog.
Pass the word around boys and girls. I hear them critters in D.C. braying for "Universal Healthcare" again...
I'll file that under my ever thickening folder titled "Federal Gummint cockups!"
Hat tip to Lawdog.
Pass the word around boys and girls. I hear them critters in D.C. braying for "Universal Healthcare" again...
Thursday, August 16, 2007
Nurse. Lye attack victim. Clinging onto life
THETFORD, Vt. (AP) -- Two months after she was maimed in a lye attack, Carmen Tarleton continues her fight for life.
Family members and friends, meanwhile, pray for her recovery from what one doctor called "the most horrific injury a human being could suffer."
Burned over 80 percent of her body when her estranged husband allegedly doused her with the chemical, she has undergone more than 16 skin graft operations and has more to come.
Now blind, with one ear burned off and another damaged, the 39-year-old nurse and mother of two remains in the intensive care unit of the burn center at Brigham and Women's Hospital in Boston, heavily sedated and unable to speak.
Hospital officials won't release her condition, but family members say it is critical, although her vital signs are stable. Doctors are optimistic about Tarleton's chances for an eventual cornea transplant that could restore her sight, but that's months away.
"It's pretty gruesome," said her father, Joe Blandin, 64, of Fairlee. "The best case scenario is Carmen's never going to be the same again. But we're hoping that there'll be enough quality of life."
Link to Ms. Tarleton's website.
How horrible! Words cannot express my anger and anguish!
Please support her in any way you can!
Thank You!
- Spook
Quick thinking nurse saves baby's life
Quick action by a Cardinal Glennon Children’s Medical Center nurse on board a plane may have helped save the life of a very sick baby.
It happened Sunday night as 27 year old Ashley Dollarhide was flying back home to St. Louis after a week of volunteer medical work overseas in Cambodia. Ashley told us about ten hours into the 14 hour flight from Taiwan to Los Angeles, the captain came on asking for medical help for a passenger. Ashley rushed to assist and found a 10 month old baby boy named Kyle very pale and having trouble breathing.
Full story
Learn more about Intra Osseous access
Refreshing to hear something positive about nurses in the news! :-)
Kudos to Ashley. Hope baby Kyle makes it out ok...
Tuesday, August 14, 2007
Of Pain Control, Teaching and Intimidation
For some strange, inexplicable reason, my internet access just died.
Just up and died.
And in just as strange fashion, it came back from the dead.
Totally bizarre.
Speaking of bizarre, ever have patients who complain about their pain being a "12/10", grimacing and carrying on, demand pain medication that-I-wanted-yesterday ?
Same patient who, upon bringing said pain medication, is found snoring away in bed with drool dribbling from mouth?
The very same patient, who, the next day insists to the physician that s/he has had a "horrible night in pain", was "ignored by the nurse. He never gave me a damned thing for my pain!", and claims that the "Darvocet did nothing for my pain!" - despite having being found as above... snoring in bed with drool dribbling from the mouth?
Well, I'm sure some of you somewhere have met this patient.
I'm just talkin' because it seems that off late, 5 out of my load of 7 patients per night seem to be of this kind. The gorked-out-of-their-minds type who demand more and more meds and then wonder why the hell do they feel constipated, bloated, nauseated and "funny".
Speaking of constipated and funny - how about the ones who demand opiates because their "stomach hurts". Yeah, it hurts. It hurts because you've been doping yourself on so much pain meds that you've got "gas pains". Taking more morphine and lying in bed ain't gonna help - it's only gonna make it worse.
It is, of course, at this very point then that you are accused of being a "mean nurse". I think people in general don't like being told "No."
Don't get me wrong. I acknowledge that a hernia repair can be painful. Hell, someone just cut you up and sewed you back on. I know it hurts. And for some of you, it's probably the worst pain in your life. Alls I want folks to think about is that every med and every intervention carries consequences and risks. I find it distressing that so many think their post-op recovery is going to be "pain free" - even the ones who end up getting say fusion surgery from T1 to L4 vertebrae because of scoliosis.
Dude, you just had a 14 hour surgery where they ripped your back and built you a new one. Do you honestly think you are going to be pain free?
And of course, you have the concerned, worried family.
Concerned Girlfriend: "Can't you see he is in pain? Why don't you give him his Xanax?"
Spook: ('Ummm, yeah. Xanax for pain control on a post-op ACF guy. That'll work!') "Ummm. I'm sorry but I haven't assessed the patient yet. I need to see him and assess him before I can intervene".
Concerned Girlfriend: (annoyed) "But he's hurting real bad! How can you just sit around and do nothing?"
[I was faxing med orders to pharmacy. Unless pharmacy has med orders, I can't even pull out a Tylenol, much less the PCA and Dilaudid bolus per orders]
Spook: "Ma'm, I'm sorry but unless I assess his condition, I cannot and I will not intervene. He can end up having complications that could be potentially fatal. I'm not going to risk his life for wont of patience and time. I understand you are concerned about his pain, but you have to let me do my job."
Concerned Girlfriend: "That's so easy for you to say! I don't think you understand at all!" (Twirls on heel and walks away in a huff).
Barely 5 minutes after this conversation, patient has had a 1 mg bolus (instead of the 2 mg ordered) of Dilaudid, a PCA set up and explained and pain down to a 4 (and falling). All it took was 5 minutes - yes, I realise, 5 minutes of pain... but it was 5 minutes that potentially prevented a serious complication.
I actually like assisting family members in dealing with their loved ones illness - teaching is a secret passion of mine. Symptoms (such as pain, fever etc.) often tell a wide and varied story. Rather than jumping at the first sign of a symptom and attempting to "cure it", it's better to assess and think for a while. This is why, for example, I prefer to give Toradol to my hysterectomy patients rather than the Morphine ordered for their abdominal pain because it has been my experience that the anti-inflammatory action of Toradol kills their pain better than the masking-opiate effect of morphine. Also, if the Toradol doesn't work, I at least have the stronger dose of Morphine to fall back on.
Now if Concerned Girlfriend had given me 30 seconds of her time, I could have patiently explained me reasons to her. But she didn't and all it made for was an unpleasant experience necessitating a rant on my blog now.
Family members who follow you around with a notepad and pencil, jotting down everything and anything you do, waiting for you to make a "mistake" really get on my nerves. It destroys the atmosphere of mutual assistance and trust. Not helping anyone and least of all the patient. If you have an issue with the way I work, please pull me aside and bring it up to me. If we can't resolve it, I'll direct you to my boss.
But please. Please. Please, don't try to "intimidate me". It doesn't work. I don't get "intimidated into doing my best" - I just get royally pissed off.
Just up and died.
And in just as strange fashion, it came back from the dead.
Totally bizarre.
Speaking of bizarre, ever have patients who complain about their pain being a "12/10", grimacing and carrying on, demand pain medication that-I-wanted-yesterday ?
Same patient who, upon bringing said pain medication, is found snoring away in bed with drool dribbling from mouth?
The very same patient, who, the next day insists to the physician that s/he has had a "horrible night in pain", was "ignored by the nurse. He never gave me a damned thing for my pain!", and claims that the "Darvocet did nothing for my pain!" - despite having being found as above... snoring in bed with drool dribbling from the mouth?
Well, I'm sure some of you somewhere have met this patient.
I'm just talkin' because it seems that off late, 5 out of my load of 7 patients per night seem to be of this kind. The gorked-out-of-their-minds type who demand more and more meds and then wonder why the hell do they feel constipated, bloated, nauseated and "funny".
Speaking of constipated and funny - how about the ones who demand opiates because their "stomach hurts". Yeah, it hurts. It hurts because you've been doping yourself on so much pain meds that you've got "gas pains". Taking more morphine and lying in bed ain't gonna help - it's only gonna make it worse.
It is, of course, at this very point then that you are accused of being a "mean nurse". I think people in general don't like being told "No."
Don't get me wrong. I acknowledge that a hernia repair can be painful. Hell, someone just cut you up and sewed you back on. I know it hurts. And for some of you, it's probably the worst pain in your life. Alls I want folks to think about is that every med and every intervention carries consequences and risks. I find it distressing that so many think their post-op recovery is going to be "pain free" - even the ones who end up getting say fusion surgery from T1 to L4 vertebrae because of scoliosis.
Dude, you just had a 14 hour surgery where they ripped your back and built you a new one. Do you honestly think you are going to be pain free?
And of course, you have the concerned, worried family.
Concerned Girlfriend: "Can't you see he is in pain? Why don't you give him his Xanax?"
Spook: ('Ummm, yeah. Xanax for pain control on a post-op ACF guy. That'll work!') "Ummm. I'm sorry but I haven't assessed the patient yet. I need to see him and assess him before I can intervene".
Concerned Girlfriend: (annoyed) "But he's hurting real bad! How can you just sit around and do nothing?"
[I was faxing med orders to pharmacy. Unless pharmacy has med orders, I can't even pull out a Tylenol, much less the PCA and Dilaudid bolus per orders]
Spook: "Ma'm, I'm sorry but unless I assess his condition, I cannot and I will not intervene. He can end up having complications that could be potentially fatal. I'm not going to risk his life for wont of patience and time. I understand you are concerned about his pain, but you have to let me do my job."
Concerned Girlfriend: "That's so easy for you to say! I don't think you understand at all!" (Twirls on heel and walks away in a huff).
Barely 5 minutes after this conversation, patient has had a 1 mg bolus (instead of the 2 mg ordered) of Dilaudid, a PCA set up and explained and pain down to a 4 (and falling). All it took was 5 minutes - yes, I realise, 5 minutes of pain... but it was 5 minutes that potentially prevented a serious complication.
I actually like assisting family members in dealing with their loved ones illness - teaching is a secret passion of mine. Symptoms (such as pain, fever etc.) often tell a wide and varied story. Rather than jumping at the first sign of a symptom and attempting to "cure it", it's better to assess and think for a while. This is why, for example, I prefer to give Toradol to my hysterectomy patients rather than the Morphine ordered for their abdominal pain because it has been my experience that the anti-inflammatory action of Toradol kills their pain better than the masking-opiate effect of morphine. Also, if the Toradol doesn't work, I at least have the stronger dose of Morphine to fall back on.
Now if Concerned Girlfriend had given me 30 seconds of her time, I could have patiently explained me reasons to her. But she didn't and all it made for was an unpleasant experience necessitating a rant on my blog now.
Family members who follow you around with a notepad and pencil, jotting down everything and anything you do, waiting for you to make a "mistake" really get on my nerves. It destroys the atmosphere of mutual assistance and trust. Not helping anyone and least of all the patient. If you have an issue with the way I work, please pull me aside and bring it up to me. If we can't resolve it, I'll direct you to my boss.
But please. Please. Please, don't try to "intimidate me". It doesn't work. I don't get "intimidated into doing my best" - I just get royally pissed off.
Monday, August 6, 2007
Diagnosis: Benign Sinus Tachycadria
Scared the pee out of me!
I showed up at work 1845 sharp. Collected my things and started getting ready for report. I'd woken up just an hour or two earlier (my usual routine) and was feeling a little "queer" - which I attributed to my having to grab some food via drive through while having just a "Vault" energy drink and thus miss usual food intake. I fully intended to eat something during report.
So, I get to work and I notice that for some reason, my mouth/oral mucosa was feeling super dry. It irritates me when my throat is parched so I drank a full glass of water. Still felt queasy.
Then noticed that my heart was thumping.
Made me feel worse. You know that kind of uneasy, queasy feeling you get when your heart is pounding but won't stop? Like you just ran 2 miles and stopped all of a sudden and felt your heart hammering away? That's what I was feeling.
All the way walking from kitchenette to report room, it seemed like I was struggling for air.
I went in and sat down but my discomfort didn't go away. I was sitting there fidgeting and a co-worker asked if I was ok. "You fine? You're flushed red".
No chest pain. But noticeable SOB now. Thumping chest still there. I keep telling myself "anytime now. It's gonna stop anytime now. Just give yourself a minute and relax..."
I walked outside and took a vital sign cart and hit the BP button while I slapped on the pulse ox probe to finger....
Heart Rate: 157/min
Blood Pressure: 161/102
Holy Toledo! My baseline is HR 58-62. BP 130/70
I took a few deep breaths, pursed my lips and tried a Valsalva or two.
No good... HR still 158 and climbing.
Began my massage my carotids to stimulate baro receptor response while slow breathing.
HR still 160! Feeling all queasy and crummy. Definitely panting for breath by now (breathing 44 times a minute).
Co-worker dragged me to an empty patient room and slapped a 3 lead monitor on my chest. Strip seemed fine. Definitely sinus tachycardia.
For the next half hour or so, I tried everything I could remember and everything the charge nurse suggested. No help. HR still up and so is the BP. She kept insisting that I needed to go to the ER NOW... but I kept demurring and deferring.
My mind kept saying "This is nuts. This shouldn't be happening!" over and over again.
Finally, grudgingly, 60 minutes post onset of symptoms; I let charge nurse wheelchair me down to ER. 12 lead EKG comes out ok. Kept me under observation for 90 mins then turned me lose. Told me to stay off stimulants and to follow up with my primary doctor.
Slowly drove home.
Very bothered by the whole episode.
I know I can stand to lose about 5 lbs. I drink that "Vault" and "Mountain Dew" and tons of good "coffee" on a regular basis without any trouble so far. I've also been cutting back on my meat intake and don't eat candy, pies, chocolate or ice cream.
There was no expectation for prolonged, unabatted, tachycardia! I don't take any meds, eat a pretty decent diet (better than when I was in college anyway) and don't have any medical history or allergies.
Like I said: Scared the pee outta me!
Guess I can add "benign tachycardia" to my medical history now!
I showed up at work 1845 sharp. Collected my things and started getting ready for report. I'd woken up just an hour or two earlier (my usual routine) and was feeling a little "queer" - which I attributed to my having to grab some food via drive through while having just a "Vault" energy drink and thus miss usual food intake. I fully intended to eat something during report.
So, I get to work and I notice that for some reason, my mouth/oral mucosa was feeling super dry. It irritates me when my throat is parched so I drank a full glass of water. Still felt queasy.
Then noticed that my heart was thumping.
Made me feel worse. You know that kind of uneasy, queasy feeling you get when your heart is pounding but won't stop? Like you just ran 2 miles and stopped all of a sudden and felt your heart hammering away? That's what I was feeling.
All the way walking from kitchenette to report room, it seemed like I was struggling for air.
I went in and sat down but my discomfort didn't go away. I was sitting there fidgeting and a co-worker asked if I was ok. "You fine? You're flushed red".
No chest pain. But noticeable SOB now. Thumping chest still there. I keep telling myself "anytime now. It's gonna stop anytime now. Just give yourself a minute and relax..."
I walked outside and took a vital sign cart and hit the BP button while I slapped on the pulse ox probe to finger....
Heart Rate: 157/min
Blood Pressure: 161/102
Holy Toledo! My baseline is HR 58-62. BP 130/70
I took a few deep breaths, pursed my lips and tried a Valsalva or two.
No good... HR still 158 and climbing.
Began my massage my carotids to stimulate baro receptor response while slow breathing.
HR still 160! Feeling all queasy and crummy. Definitely panting for breath by now (breathing 44 times a minute).
Co-worker dragged me to an empty patient room and slapped a 3 lead monitor on my chest. Strip seemed fine. Definitely sinus tachycardia.
For the next half hour or so, I tried everything I could remember and everything the charge nurse suggested. No help. HR still up and so is the BP. She kept insisting that I needed to go to the ER NOW... but I kept demurring and deferring.
My mind kept saying "This is nuts. This shouldn't be happening!" over and over again.
Finally, grudgingly, 60 minutes post onset of symptoms; I let charge nurse wheelchair me down to ER. 12 lead EKG comes out ok. Kept me under observation for 90 mins then turned me lose. Told me to stay off stimulants and to follow up with my primary doctor.
Slowly drove home.
Very bothered by the whole episode.
I know I can stand to lose about 5 lbs. I drink that "Vault" and "Mountain Dew" and tons of good "coffee" on a regular basis without any trouble so far. I've also been cutting back on my meat intake and don't eat candy, pies, chocolate or ice cream.
There was no expectation for prolonged, unabatted, tachycardia! I don't take any meds, eat a pretty decent diet (better than when I was in college anyway) and don't have any medical history or allergies.
Like I said: Scared the pee outta me!
Guess I can add "benign tachycardia" to my medical history now!
Saturday, August 4, 2007
Perspectives
Y'all need to read this.
Now!
Start off here with Matt @ Better and Better
Touch base with AD @ A Day in the Life of an Ambulance Driver
Round off with Babs @ Just Peachy!
Read 'em all... in that order.
And grab a box of tissues on the way...
Now!
Start off here with Matt @ Better and Better
Touch base with AD @ A Day in the Life of an Ambulance Driver
Round off with Babs @ Just Peachy!
Read 'em all... in that order.
And grab a box of tissues on the way...
Wednesday, August 1, 2007
"Hey Spook? I can't get a BP ..."
Assignment board for the noc:
RNs - Mar, Spook, Jane
Tech - Linda
Census - 21
Given our "staffing ratios grid" ... we didn't rate an extra nurse. We were expected to start off with 7 patients per nurse. "OK", I asks the charge nurse (who of course, isn't available on nights) "Do we have anyone for call in case we get admits?"
Guess what the charge nurse said? Yep! She said: "You have no one on call".
I log on to a computer and run up a quick list for hospital wide census - Medical has 1 bed free. CVCU and step down are full. ICU has 4 beds free. Neuro has 1.
That means, our floor would be getting all the admits for the night. This (Medical and general overflow admits) has been happening ever since they closed down the MOU (Medical Oncology Unit) and it has been a source of great frustration and resentment amongst staff on our (Surgical) floor. TPTB figure "A nurse is a nurse is a nurse is a nurse. Specialties be damned!"
And naturally, since we don't rate a charge nurse position for nights, I assume 'Charge' as well.
And I have one tech for the whole floor who is too new to the game. Great! Gonna be one long night...
Take quick report and start my rounds.
Amongst the chores of assessment, I also hang TPN (bag #19) on one of our "residents" (i.e. Patient who has been admitted to the floor for a long time with no general progress or change in condition). Start PM antibiotics for my post-op patients. Do a dressing change on a massive mastectomy patient awaiting a wound-vac (Negative Pressure Wound Therapy) consult in the morning - which I thought was pretty 'cool' (I needed one nurse to lift open her chest wall flap while I packed wet kerlix into the wound. Patient's wound was so extensive and deep, I could shove both hands all the way into the cavity! Used up at least 2 fat rolls of Kerlix, a pack of 4x4s and 2 ABD pads minimum per dressing change. If you are wondering what it all means - for a sub-acute surgical floor... that's a lot! Spending 20+ minutes doing a single dressing change on one patient is high intensity/acuity for a sub-acute General Surgical floor).
Medicate for pain as needed. Switch empty PCA cartridges and clear PCA and IV pumps for I/O.
Before you know it, you look at the clock and it's 2300 hrs. The 3-11 shift staff start winding up and leaving the floor. A couple of the nurses are still around - they need to finish charting. Taking their cue, I settle down and begin charting my own assessments.
"Hey Spook, gotta minute?"
I look up. It's Mar.
"Yeah, whatcha need?"
"Can you start an IV on Mr. Link in room 71? He's a post-op bowel resection and has IV Flagyl and Kefzol. I tried twice but his veins keep blowing".
"Sure, I'll give it a shot".
Apparently, I am the "go to" guy for IV starts. I don't have a ton of experience myself and working a surgical floor doesn't help much - but I did 2 months in the ER when I got out of nursing school and was taught the finer points of IV starts by a kick-ass ER nurse with over 20 years of experience.
Mr. Link is a pleasant gentleman in his 30s and quick inspection reveals tree-trunk veins .
This shouldn't take too long...
Or so I thought. But upon my first attempt, I found out that Mar was right. For some inexplicable reason, you'd insert the needle, get a good "flash" of blood in the chamber, and then advance the plastic catheter ... only to have the vein "blow". That was the fate of my first and second attempts. I sat and thought for a minute and then recalled a similar experience during my ER rotation. I took off the tourniquet and tried again...
Bingo! A #20 inserted on his left wrist. Feeling pretty pleased with myself, I decide to go the extra mile and do a good "tape job" on the IV site. I was just hooking the IV tubing back onto the new IV site when the Tech, Linda, pokes her head into the room and says "Hey Spook, I can't get a BP on Room 97".
"Do a manual", I said, without even turning my head.
"I tried. But I still can't get one".
Something made the back of my neck tingle.
"Ok thank you. I'll check it out".
After making sure Mr. Link was comfortable, I headed over to room 97.
A brief history.
Ms. Smith is 78 years old. A nursing home resident, she had been admitted by her primary care Dr. Guy for rule/out Bowel Obstruction Vs Ileus. I had assesed the patient at the start of my shift. Good vital signs (BP 128/90, HR 80, Resp 16, afebrile with SpO2 of 100% on 2L O2 via NC). Had a small chat with pt. while assessing - hypo active BS, no flatus but presenting with diarrhea (which seems "strange" given that the patient's admitting diagnosis is impaired bowel function... but it has been known to happen). X-Rays in ER showed no obstruction of bowels (essentially normal bowels) while ER labs were inconclusive. Patient denies pain, but is very pleasant, alert and oriented x3... just complains of being "tired". Last pain killer was 2mg MSO4 IV at 1500 hrs. NG tube to medium intermittent suction inserted at 1600. Drainage was brown colored then.
Reassessed pt. at "I/O time" (2200hrs). Patient essentially same as before. Slightly drowsy - but good U/O (over 400cc from foley). Follows commands and is co-operative. NG drainage still brown colored.
Cue to the present (about 0100 am). I walk into the room and quietly try a manual. Can't get it either. So I try palpating pulses - on radial, brachial, carotid, dorsalis pedis, posterior tibialis, Popliteal and finally femoral.
I could only palpate a femoral pulse! Pulse rate told me "56 bpm"!
Damn...
Instantly whipped stethoscope of my neck to listen to apical - I got a reassuring (if somewhat borderline tachycardic) rate of 96 bpm ("lubb-dupp"). I trust the apical auscultation over the femoral palpation.
I stepped back and looked at patient and saw patient was "sound asleep". That's when it hit me - despite my poking and prodding her, she hadn't responded much.
Shit! You idiot! Don't just assume a patient is sleeping!
I called out patient's name. Elicited a slight response. Called out name while proceeding to shake arm a little bit. Patient opened eyes to look at me... appeared v.drowsy and barely able to hold conversation. While this was going on, I tried to raise patient's arm one more time to check pulses and noticed that patient couldn't keep arms extended in air - dropped to bed the minute I released them. I snapped my flashlight out and did a quick pupillary check - PERRL with brisk accommodation.
Problem still persists - I still don't know patient's BP and now she seems to have altered mentation/status. I calmly told the tech: "Get me the Doppler and the jelly!" Then, knowing my unit and our 'restocking procedure' (or it's lack there off), I told the tech "if you can't find the Doppler gel, get me some KY jelly from the store room".
"Shall I get the crash cart?"
"No, not yet anyway. Thanks for asking but you wouldn't be able to get it out without my keys. Get the Doppler please".
While the tech flees to find the Doppler, my heart is pounding! I grab the accucheck machine and do a stat BG check. Machine bleats "80".
"Damn! Normal BG".
I take a look at her NG tube output - still brown colored but it is showing signs of red flecks/clots/discharge. Not much to be concerned - but a change nevertheless.
By this time, the tech has returned with the Doppler. I proceed immediately to try and get a Doppler pulse. Vessel occludes at 40 systolic!
Damn! Double damn!
I punch in the desk number on my "charge nurse" phone and ask them to page Dr.Guy STAT! Doc calls back and conversation goes something like this:
"Dr. Guy? Hi, this is Spook, RN here at Tiny City Medical. I have Ms. Smith here with no palpable pulse and cannot get a BP. Patient is very lethargic and responds only to pain or vigorous physical stimulus".
"Yeah. She's a little hard to measure up. What's her vitals?"
Didn't I just tell you I can't get a BP on her?
"Uhhh Doc. Last vitals were over 2 hours ago and she was 128/80 with HR: 72. I have an apical pulse right now which is 96. No BP - vessel occludes at 40 with Doppler. Urine output for the past 4 hours is exactly zero cc. Resps 22. I don't think she is perfusing well - I can't get a pulse ox reading and her extremities are cold. She looks pale but not cyanotic. Blood glucose 80. Fluids running at 125/hr. Last medication given was Morphine 2 megs IVP at 1600 (over 8 hours ago)."
"Ok. Bolus patient 500 cc over 15 minutes. I'll call you right back".
"Uhhh, that's it? Nothing else? Her NG output has changed - it was brown but now it is more reddish with specs and clots".
"No. Just push the fluids. I'll call back".
Seeing all the commotion, George calmly walks in. George is a nurse working the 3-11 shift. He was all set to go home at the end of his shift, but I asked if he'd stay and work double because we were insanely busy that night. George had agreed (of course, he would also get paid time-and-half for his troubles).
I feel much better knowing he is on the floor - George is a buddy and has been a paramedic and nurse for decades. In the midst of all this confusion, I give myself a little pat on the back for having the huevos to defy "The Almighty Staffing Ratio Grid" and keeping him around rather than send him home at the end of his shift.
My iMED pumps won't let me program a bolus of 500 cc in 15 minutes. George simply winks and unclamps the line from the pump, reattaches the line direct to the hub of the catheter sans Clave port and begins squeezing the bag with his hands. By this time, Doc calls back.
Still no appreciable BP. Patient mentation is still same. Order: Repeat bolus and admin 0.5 Narcan and repeat in 10 minutes if no change.
George walks over to get me the Narcan. With one hand still dumping in the fluids, I use the other hand to call the House Supe.
"Dude, you better get up here. I got a LOL (Little Ol' Lady) with no BP and barely any pulse".
"What the hell happened?!"
"I can't talk right now. Just get up here!"
My buddy saunters in with the Narcan.
I hand him the bag while I push the med in. Almost instantly her eyes snap open and starts darting around. I instruct my buddy to try and get a BP on her.
Apparently the 1000 cc fluid bolus did something for we managed to get a BP reading of 50/20.
*whistling sound behind my head* "Whoa! That's not a good sign"...
I turn around and see the House Supe walking in. "Call the code, Spook", he says to me.
I yank my phone out and call ICU and have them prep a room for an insta-transfer. One of their nurses hurries over to the floor. While the three nurses are in the room getting the patient ready to transfer, I run over to the desk and pack up patient's paperwork, hurriedly scribbling down the telephone orders on an order sheet.
I reach the elevator the same time they do, with the patient on the bed. I leaf through the chart and pick out the face sheet. I call patient's daughter in town and tell a sleepy voice that patient is being shifted to ICU and it would probably be a good idea to come in.
"What the hell happened?"
"Well, her BP dropped and she's very lethargic and unresponsive."
"Oh my God! I'm coming right over".
I glanced over at the foley bag - still no urine output.
Dang!
Auscultated her while we reached the floor - HR still running in the 90s. Resps 20. Failed to get a palpable BP....
Well, we got her to ICU and got her hooked up and set up. Gave report to ICU nurse.
Walked back to the floor and was instantly met with a pile of messages from my patients... each one of them asking "What took so long? I've been on the call light for hours".
*sigh* "Here's your iced tea and your Tylenol PM. Have a good night. Anything else I can do for you?"
Morning rolls around and charge nurse walks in. If I thought my night was bad, it wasn't about to get any better.
Points to my buddy and asks me indignantly: "What's he still doing on the floor?! Wasn't he supposed to have gone home last night?!"
(A very weary, tired, Spook): "No. I kept him around because it was insane up here. We have 4 post op knees - two of them sun downers who insist on climbing out of bed every 10 minutes sitting on beds whose bed alarms don't work because the beds are 30 years old. Four patients in isolation. One with aspiration pneumonia because medical is full and have no beds. I had 7 patients in gen surg all to myself spread all over the floor. Oh and did I tell you about my ICU transfer yet?"
"You could have kept the second tech!"
"But what could the tech have done? Passed meds? Done chart checks? Push fluids or get me some Narcan? Co-ordinate a transfer to the ICU? Look after my patients while I was downstairs giving report? Nah... sorry. There were 4 patients in the ER - two of them possible surgicals at shift change time and I thought it best to keep him rather than send him home and then call him back. Don't worry, I'll do the paperwork".
Charge Nurse saw that I was tired, hungry and just wanted to get the hell outta there. Wisely chose to drop issue and let me get back to charting.
Didn't get home till late in the day.
RNs - Mar, Spook, Jane
Tech - Linda
Census - 21
Given our "staffing ratios grid" ... we didn't rate an extra nurse. We were expected to start off with 7 patients per nurse. "OK", I asks the charge nurse (who of course, isn't available on nights) "Do we have anyone for call in case we get admits?"
Guess what the charge nurse said? Yep! She said: "You have no one on call".
I log on to a computer and run up a quick list for hospital wide census - Medical has 1 bed free. CVCU and step down are full. ICU has 4 beds free. Neuro has 1.
That means, our floor would be getting all the admits for the night. This (Medical and general overflow admits) has been happening ever since they closed down the MOU (Medical Oncology Unit) and it has been a source of great frustration and resentment amongst staff on our (Surgical) floor. TPTB figure "A nurse is a nurse is a nurse is a nurse. Specialties be damned!"
And naturally, since we don't rate a charge nurse position for nights, I assume 'Charge' as well.
And I have one tech for the whole floor who is too new to the game. Great! Gonna be one long night...
Take quick report and start my rounds.
Amongst the chores of assessment, I also hang TPN (bag #19) on one of our "residents" (i.e. Patient who has been admitted to the floor for a long time with no general progress or change in condition). Start PM antibiotics for my post-op patients. Do a dressing change on a massive mastectomy patient awaiting a wound-vac (Negative Pressure Wound Therapy) consult in the morning - which I thought was pretty 'cool' (I needed one nurse to lift open her chest wall flap while I packed wet kerlix into the wound. Patient's wound was so extensive and deep, I could shove both hands all the way into the cavity! Used up at least 2 fat rolls of Kerlix, a pack of 4x4s and 2 ABD pads minimum per dressing change. If you are wondering what it all means - for a sub-acute surgical floor... that's a lot! Spending 20+ minutes doing a single dressing change on one patient is high intensity/acuity for a sub-acute General Surgical floor).
Medicate for pain as needed. Switch empty PCA cartridges and clear PCA and IV pumps for I/O.
Before you know it, you look at the clock and it's 2300 hrs. The 3-11 shift staff start winding up and leaving the floor. A couple of the nurses are still around - they need to finish charting. Taking their cue, I settle down and begin charting my own assessments.
"Hey Spook, gotta minute?"
I look up. It's Mar.
"Yeah, whatcha need?"
"Can you start an IV on Mr. Link in room 71? He's a post-op bowel resection and has IV Flagyl and Kefzol. I tried twice but his veins keep blowing".
"Sure, I'll give it a shot".
Apparently, I am the "go to" guy for IV starts. I don't have a ton of experience myself and working a surgical floor doesn't help much - but I did 2 months in the ER when I got out of nursing school and was taught the finer points of IV starts by a kick-ass ER nurse with over 20 years of experience.
Mr. Link is a pleasant gentleman in his 30s and quick inspection reveals tree-trunk veins .
This shouldn't take too long...
Or so I thought. But upon my first attempt, I found out that Mar was right. For some inexplicable reason, you'd insert the needle, get a good "flash" of blood in the chamber, and then advance the plastic catheter ... only to have the vein "blow". That was the fate of my first and second attempts. I sat and thought for a minute and then recalled a similar experience during my ER rotation. I took off the tourniquet and tried again...
Bingo! A #20 inserted on his left wrist. Feeling pretty pleased with myself, I decide to go the extra mile and do a good "tape job" on the IV site. I was just hooking the IV tubing back onto the new IV site when the Tech, Linda, pokes her head into the room and says "Hey Spook, I can't get a BP on Room 97".
"Do a manual", I said, without even turning my head.
"I tried. But I still can't get one".
Something made the back of my neck tingle.
"Ok thank you. I'll check it out".
After making sure Mr. Link was comfortable, I headed over to room 97.
A brief history.
Ms. Smith is 78 years old. A nursing home resident, she had been admitted by her primary care Dr. Guy for rule/out Bowel Obstruction Vs Ileus. I had assesed the patient at the start of my shift. Good vital signs (BP 128/90, HR 80, Resp 16, afebrile with SpO2 of 100% on 2L O2 via NC). Had a small chat with pt. while assessing - hypo active BS, no flatus but presenting with diarrhea (which seems "strange" given that the patient's admitting diagnosis is impaired bowel function... but it has been known to happen). X-Rays in ER showed no obstruction of bowels (essentially normal bowels) while ER labs were inconclusive. Patient denies pain, but is very pleasant, alert and oriented x3... just complains of being "tired". Last pain killer was 2mg MSO4 IV at 1500 hrs. NG tube to medium intermittent suction inserted at 1600. Drainage was brown colored then.
Reassessed pt. at "I/O time" (2200hrs). Patient essentially same as before. Slightly drowsy - but good U/O (over 400cc from foley). Follows commands and is co-operative. NG drainage still brown colored.
Cue to the present (about 0100 am). I walk into the room and quietly try a manual. Can't get it either. So I try palpating pulses - on radial, brachial, carotid, dorsalis pedis, posterior tibialis, Popliteal and finally femoral.
I could only palpate a femoral pulse! Pulse rate told me "56 bpm"!
Damn...
Instantly whipped stethoscope of my neck to listen to apical - I got a reassuring (if somewhat borderline tachycardic) rate of 96 bpm ("lubb-dupp"). I trust the apical auscultation over the femoral palpation.
I stepped back and looked at patient and saw patient was "sound asleep". That's when it hit me - despite my poking and prodding her, she hadn't responded much.
Shit! You idiot! Don't just assume a patient is sleeping!
I called out patient's name. Elicited a slight response. Called out name while proceeding to shake arm a little bit. Patient opened eyes to look at me... appeared v.drowsy and barely able to hold conversation. While this was going on, I tried to raise patient's arm one more time to check pulses and noticed that patient couldn't keep arms extended in air - dropped to bed the minute I released them. I snapped my flashlight out and did a quick pupillary check - PERRL with brisk accommodation.
Problem still persists - I still don't know patient's BP and now she seems to have altered mentation/status. I calmly told the tech: "Get me the Doppler and the jelly!" Then, knowing my unit and our 'restocking procedure' (or it's lack there off), I told the tech "if you can't find the Doppler gel, get me some KY jelly from the store room".
"Shall I get the crash cart?"
"No, not yet anyway. Thanks for asking but you wouldn't be able to get it out without my keys. Get the Doppler please".
While the tech flees to find the Doppler, my heart is pounding! I grab the accucheck machine and do a stat BG check. Machine bleats "80".
"Damn! Normal BG".
I take a look at her NG tube output - still brown colored but it is showing signs of red flecks/clots/discharge. Not much to be concerned - but a change nevertheless.
By this time, the tech has returned with the Doppler. I proceed immediately to try and get a Doppler pulse. Vessel occludes at 40 systolic!
Damn! Double damn!
I punch in the desk number on my "charge nurse" phone and ask them to page Dr.Guy STAT! Doc calls back and conversation goes something like this:
"Dr. Guy? Hi, this is Spook, RN here at Tiny City Medical. I have Ms. Smith here with no palpable pulse and cannot get a BP. Patient is very lethargic and responds only to pain or vigorous physical stimulus".
"Yeah. She's a little hard to measure up. What's her vitals?"
Didn't I just tell you I can't get a BP on her?
"Uhhh Doc. Last vitals were over 2 hours ago and she was 128/80 with HR: 72. I have an apical pulse right now which is 96. No BP - vessel occludes at 40 with Doppler. Urine output for the past 4 hours is exactly zero cc. Resps 22. I don't think she is perfusing well - I can't get a pulse ox reading and her extremities are cold. She looks pale but not cyanotic. Blood glucose 80. Fluids running at 125/hr. Last medication given was Morphine 2 megs IVP at 1600 (over 8 hours ago)."
"Ok. Bolus patient 500 cc over 15 minutes. I'll call you right back".
"Uhhh, that's it? Nothing else? Her NG output has changed - it was brown but now it is more reddish with specs and clots".
"No. Just push the fluids. I'll call back".
Seeing all the commotion, George calmly walks in. George is a nurse working the 3-11 shift. He was all set to go home at the end of his shift, but I asked if he'd stay and work double because we were insanely busy that night. George had agreed (of course, he would also get paid time-and-half for his troubles).
I feel much better knowing he is on the floor - George is a buddy and has been a paramedic and nurse for decades. In the midst of all this confusion, I give myself a little pat on the back for having the huevos to defy "The Almighty Staffing Ratio Grid" and keeping him around rather than send him home at the end of his shift.
My iMED pumps won't let me program a bolus of 500 cc in 15 minutes. George simply winks and unclamps the line from the pump, reattaches the line direct to the hub of the catheter sans Clave port and begins squeezing the bag with his hands. By this time, Doc calls back.
Still no appreciable BP. Patient mentation is still same. Order: Repeat bolus and admin 0.5 Narcan and repeat in 10 minutes if no change.
George walks over to get me the Narcan. With one hand still dumping in the fluids, I use the other hand to call the House Supe.
"Dude, you better get up here. I got a LOL (Little Ol' Lady) with no BP and barely any pulse".
"What the hell happened?!"
"I can't talk right now. Just get up here!"
My buddy saunters in with the Narcan.
I hand him the bag while I push the med in. Almost instantly her eyes snap open and starts darting around. I instruct my buddy to try and get a BP on her.
Apparently the 1000 cc fluid bolus did something for we managed to get a BP reading of 50/20.
*whistling sound behind my head* "Whoa! That's not a good sign"...
I turn around and see the House Supe walking in. "Call the code, Spook", he says to me.
I yank my phone out and call ICU and have them prep a room for an insta-transfer. One of their nurses hurries over to the floor. While the three nurses are in the room getting the patient ready to transfer, I run over to the desk and pack up patient's paperwork, hurriedly scribbling down the telephone orders on an order sheet.
I reach the elevator the same time they do, with the patient on the bed. I leaf through the chart and pick out the face sheet. I call patient's daughter in town and tell a sleepy voice that patient is being shifted to ICU and it would probably be a good idea to come in.
"What the hell happened?"
"Well, her BP dropped and she's very lethargic and unresponsive."
"Oh my God! I'm coming right over".
I glanced over at the foley bag - still no urine output.
Dang!
Auscultated her while we reached the floor - HR still running in the 90s. Resps 20. Failed to get a palpable BP....
Well, we got her to ICU and got her hooked up and set up. Gave report to ICU nurse.
Walked back to the floor and was instantly met with a pile of messages from my patients... each one of them asking "What took so long? I've been on the call light for hours".
*sigh* "Here's your iced tea and your Tylenol PM. Have a good night. Anything else I can do for you?"
Morning rolls around and charge nurse walks in. If I thought my night was bad, it wasn't about to get any better.
Points to my buddy and asks me indignantly: "What's he still doing on the floor?! Wasn't he supposed to have gone home last night?!"
(A very weary, tired, Spook): "No. I kept him around because it was insane up here. We have 4 post op knees - two of them sun downers who insist on climbing out of bed every 10 minutes sitting on beds whose bed alarms don't work because the beds are 30 years old. Four patients in isolation. One with aspiration pneumonia because medical is full and have no beds. I had 7 patients in gen surg all to myself spread all over the floor. Oh and did I tell you about my ICU transfer yet?"
"You could have kept the second tech!"
"But what could the tech have done? Passed meds? Done chart checks? Push fluids or get me some Narcan? Co-ordinate a transfer to the ICU? Look after my patients while I was downstairs giving report? Nah... sorry. There were 4 patients in the ER - two of them possible surgicals at shift change time and I thought it best to keep him rather than send him home and then call him back. Don't worry, I'll do the paperwork".
Charge Nurse saw that I was tired, hungry and just wanted to get the hell outta there. Wisely chose to drop issue and let me get back to charting.
Didn't get home till late in the day.
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