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"!


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.

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.

1 comment:

ERnursey said...

Where you working that the ratio is 1:7? In Cali, floor RN has 5 and IMCU has 4, ICU 2. 7 with the acuity you portray is insane!