Saturday, September 29, 2007

How I spent my "Bonus Pay"

Hospital had a windfall the previous fiscal year. Since we are a "not for profit" organization, management instituted a "Revenue sharing scheme" to distribute a share of the windfall (the other part being used for hospital upgrades etc.).

So, being the responsible, prudent young adult that I am, I salted it aw...

So being the fun loving, young adult that I am, I went out and bought myself:

Even had my first lessons yesterday too :)

My dream has always been to be able to play one instrument each from: the percussion, the wind and the string families. I already know how to play the drums (percussion), so the choice was between the violin or the saxophone.

I'm all excited now (and busy annoying my neighbors as well!)

Monday, September 24, 2007

Now THERE's a sports fan!

It's the AFL (Australian Football League) Grand final and a man makes his way to his seat right on the wing. He sits down, noticing that the seat next to him is empty.

He leans over and asks his neighbour if someone will be sitting there.

"No," says the neighbour. "The seat is empty."

"This is incredible", said the man. "Who in their right mind would have a seat like this for AFL Grand final and not use it?"

The neighbour says "Well, actually, the seat belongs to me. I was supposed to come with my wife, but she passed away. This is the first AFL Grand final we haven't been to together since we got married in 1967."

"Oh ... I'm sorry to hear that. That's terrible. But couldn't you find someone else, a friend or relative, or even a neighbour to take the seat?"

The man shakes his head "No, they're all at the funeral."

Heh! That's dedication, wot? LMAO!

Up the Irons!

I’m rediscovering my love for this band.

All over again.

A tiny selection of their extensive discography:

"Running Free" - live at Donnington, UK:

"Wasted Years" from their Somewhere In Time album:

"Fear of the Dark" performed live at Rio de Janeiro, Brazil:

(I just love Bruce's evil laugh in that last video!)

Is "free" healthcare, really the best healthcare?

John Stossel does an exclusive report for a new "20/20" segment.

Check it out:

Check out the whole deal (it's a 6 part video) : Part 2, Part 3, Part 4, Part 5 and Part 6.

I love John Stossel. Sometimes, I wish he wasn't the only lone voice of sanity in the wilderness.

It really is an "eye opening" report and provides a different take from the usual drivel about the need for "universal" health care. Folks who've had socialized medicine all their lives don't know any different - I know, I used to be one of those. Folks who have private health care suffer from the "Grass is greener" syndrome and wish for universal care, not knowing what they are liable to get.

Does health care in America need fixin'? Sure! I'm not saying the current scenario is healthy. I just don't think eliminating competition and choice by switching to universal care is the right way to go about it.

What we need is more competition, not less.

Sunday, September 23, 2007

Y'all been talkin' smack 'bout me?

Meh! My reputation precedes me, yeah?

The CT scan


Had the CT. Good thing I took the night off because I didn't feel "ok". I wasn't nauseated or anything... but I just didn't "feel ok".

So I drinks my prep with my dinner the night before.

Pitch, toss and turn in bed trying to get some sleep during the night - my usual "awake time".

Get up all grouchy after three hours of sleep when my alarm goes off. I've given myself an hour and half to shower/get ready and drink my morning cat-scan prep.

All goes relatively smoothly (warning to anyone considering/needing a cat scan in the future. If you don't hate Banana, take the Banana flavor smoothie. The Berry flavored one sucks!)

I drive meself over. Pre-registration goes fine.

I'm taken down to "pre-scan" area. Requisite health history is repeated. I see a very nervous CAT Tech student hovering around. She asks if I don't mind if she started the IV on me. I smile and say "not a problem!” I remember being a student once - we all gotta practice, right? And who better to practice on and build confidence than on a young feller with tree trunk veins? :)

Right away, while she is prepping, I notice ... well, "technique issues" (My tourniquet is not too tight, she's trying to "see" the vein rather than "feel" it, and when she thinks she's found one, she doesn't try to see/feel it's direction etc.) I generally try and keep my mouth shut - I don't want to come across as a smartypants. The only suggestion I offer is when she does the skin prep - gently I tell her with a smile: "Ma'm (though she is probably 18 years old), it works better if you really rub and scrub it during your process".

She blushes and proceeds to vigorously scrub my skin.

At this point she is ready to cannulate me and I can tell she is dreadfully nervous. I'm used to seeing folks poke my veins (I donate blood Q 2 months and watching an expert nurse drop that 16 G needle into my vein is one of the highlights of the whole process :D)... but I figure that my gawking on would probably be counter productive.

In stead, I try and play the "usual patient" routine and pretend to 'close my eyes in anticipation of the "painful stick" that is to come'.

I feel the poke and I feel her digging around. It isn't painful yet, just a tad bit uncomfortable. I crack my left eye open on the sly to see what's going on. She is digging around, her forehead knotted in concentration, trying to get that magical "flash" in the blood chamber signaling a successful IV stick.

After a dozen seconds of digging around, she flips over her shoulder to look at her preceptor - as if to plead for help. Preceptor says quietly, "Pull it out. Let me take a crack at it".

So she pulls out. Disappointment writ all over her face. She tapes my failed site down with LOTS of gauze and too little tape.

I bite my tongue yet again rather than do some 'constructive criticism' about the need for "pressure on the wound", "elevate the site over the heart for a few minutes" and "fold a piece of gauze over to form a square and use a good amount of tape (especially on males because of abundance of coarse hair) and use pressure when applying the tape/gauze combination to ensure restriction of blood flow".

I make a mental note to talk to the CT department about their preceptorship of students. I note a distinct lack of guidance and encouragement from the "preceptor".

For some reason, I figured this might be a 'nice' time to step in.

I volunteered that I'd be willing to have the student have another crack at my other arm for sticking a vein. The whole flurry off "Are you sure?" type questions followed and each time I answered in the affirmative - I was willing to have the student take another shot at cannulating me.

The student looked like any student would at this point - grateful that they were being given a second chance... and yet horrified about facing her past while trying to achieve a positive outcome again!

(I know precisely what the student was feeling - not too long ago, I too was a "student preceptee" but in a Trauma ER. There, I was schooled in the fine arts of "IV cannulation" by a kick ass ER nurse who had been at that job for 22+ years. She rode my ass unmercifully on all aspects of the job (but her forte seemed to be IVs) - but it is all thanks to her that I picked up some of the salient points of IV insertion.

And boy! Am I thankful she rode my butt back then! Where I work right now, I am the "go to guy" for starting IVs - never mind that I'm not exactly "Mister 20 years of experience!")

But anyway, I extended my Right Arm. Stretched it out good.

As the student (let's call her "ST" sat down with her supplies, I talked in a low, calm, assuring voice:

Me: "You're gonna do great this time. Trust me, I know"

ST: (half laughingly) "Yeah? I hope so"

(Tries to tie the tourniquet on my arm. Ties it on too loose again)

Me: "Pardon me. I don't mean to be a jerk, but I think you might get better results if you tied that tourniquet on a lot tighter. Now, don't worry about 'discomfort' - remember, it's important that you get the IV in, right?"

ST: (Looks at me a bit quizzically but decides to follow through) "Ok. Let's try that again...

Me: (As ST is re-trying) "A little harder... a little more... that looks about good!" I smile

ST: (Smiles) "Ok then! Let's get a vein. Ope....."

Me: And before she can begin her sentence, I'm pumping my fist. "Ready when you are", I grin.

ST: (blushes) "Ok, Let me take a look".

At this point, her preceptor is curious - I've been giving an awful lot of feedback to her student. I'm pretty sure it's something she doesn't expect her average CT scan patient to give... her question doesn't strike me as something out of the ordinary:

"So, are you a CT scan tech? Do you work around here?"

Me: "No M'am!" I grin. "I'm a registered nurse. I work upstairs. I send folks down to you guys for their CT scans all the time."

I quickly turn my attention towards her student, who is still furiously looking for a vein. As gentle as I can, I tell her "try to feel for one. When you push/bounce on a good vein, it should feel spongy. Looks are not all they seem - sometimes a vein that looks good is probably not the best one to hit".

Probably not the best description - but given the circumstances, it should work. I have very good veins on both my arms. She just needs some pointed guidance. I try to guide her, gently; towards the rope of the vein in my AnteCube...

Me: "Little more medial.... little more... just a tad bit more... ok, you're close. You should able to feel a spongy, thread like structure. You're roughly close to the middle of my inner elbow."

Gently, I reach over and grab her index finger... and guide it to my Median Cubital/Basilic vein (for a clickable look at the anatomical position of this vein/site - click here! (WARNING: "Graphic content" of human cadaver used for illustration purposes!)... and gently press on the site.

"There... feel the spongy nature? You try it"

ST: "Ohhh! Ok! I feel it! You're right! It's nice and ... and... 'spongy'!"

Well! I wish every one had veins like I do! But that's a lesson you're gonna have to learn on your own. First things first though...

Me: "Ok. Now try to see which way that vein goes. Try and get a 'feel map'. Is it going straight up and down? Is it going off at an angle? Is it straight for an inch or so or does it get crooked?"

ST is busy trying to concentrate and palpate my vein. Judging by the pressure exerted by her fingertips, I can tell she's arrived at a decent understanding of the direction my vein takes.

She announces excitedly: "Ohhh! You're vein is good and straight! But it just goes off at an awkward direction in your arm!"

I tell her that while anatomy textbooks try and provide a good terrain map, human beings are individuals and are thus bound to be varied. I tell her to get her "stuff" ready (tape, Tegaderm, saline lock). She vigorously rubs the IV site (Hey! She's learning already! :)) in preparation.

As she's about to insert the IV, I tell her to pause and take a good, deep breath. Then I look her in the eye and say "You can do this. Just remember the position you just found, the direction the vein took, spread the skin before you poke and remember to start at a low angle and go slowly. Don't worry about hurting me - you won't. I know you can do it right".

I then turned away and closed my eyes.

I felt the poke... and felt her digging around some. I resisted the urge to look ... just maintained the calm demeanor. Suddenly I heard a yelp:

"Blood return! BLOOD RETURN! Blood Return!"

I felt her clumsily retract the needle - while forgetting to put pressure on the IV site.... almost instantly; I felt blood flow down my elbow through the IV site.

ST: "CRAP!", she swore. But in a frenzy of activity, she managed to hook up a saline lock in no time. As she was wiping up some of the blood, I opened my eyes and winked at her...

Me: "So, it wasn't that hard was it?", I said with a grin.

ST: *blushing* "It was! But I still made many mistakes!"

Me: "Well, those weren't critical mistakes. And you did choose to overcome you fear and failure to give a good attempt again. I'd call this one a "decent try". :)

ST: *still blushing* "Really?! Wow! I thought I'd screwed up major time!"

Me: "ST, nobody is a born IV sticker... except me, of course!" I grin. "But you did well, given your circumstances. Just remember: Dependent arms, tight tourniquets, feel the vein and stick it with confidence", I said with a wink and a smile.

And with that, I was ready to head over to the CT scan....

So, I walks into the CT scan unit.

Facing that big "donut like thing", I quietly tells myself "this is it Spook. Hope the results come out all ok!”

I take a good deep breath, walk over to the counter and take off all "extraneous items" - watch, keys, cell phone, wallet, dog tags, and my belt.

I quietly lie down on the bench. They cover me with a blanket and ask me to lower my pants to my knees. I comply. Then they ask me to raise my arms over my head.

First we "shoot" my abdomen "without" IV contrast [IV contrast consists primarily of Iodine solution]. I 'travel' in and out of the donut - being asked to "inhale and hold my breath" every so often while they take pictures of my abdomen before being told to exhale.

The night before (and this morning), I have swallowed what's known as "Redi-Cat" - a solution that primarily consists of a Barium Sulfate suspension. This solution has been swimming around in my body for a while and now they've taken pictures of by innards - the Barium Sulfate helps identify certain body organs and innards.

Then comes the "Pictures with IV contrast part".

During this session, they "shoot" (literally deposit about a 100 ml of solution real fast. This is the primary reason why CT scans require "good" venous access) Iodine contrast solution directly into my veins.

I was told to expect "feeling warm all over".

Lemme tell ya, it ain't nothing like you think it would be!

When they says "warm all over" - they means "warm all over". And not a "slumber-party-under-the-comforter-warm".

WARM! As in "hot"! You suddenly feel freaking HOT all over. From you head and shoulders, your chest.... to your belly... then in a very awkward way... your genitals too (men - by that I means your testicles and penis!)... before it reaches down to your feet and toes.

All of this happens within seconds! So while you're there feeling semi-assaulted; you're 'drawn' into the CT machine again. Again the command comes: "Breathe in.... Hold your breath".

They did this once and I felt semi-nauseated. Still trying to fight off/get used to that funky, hot, warm feeling between my legs and in my gut, I was slid into that machine again.

Once again, I was told to "Breath in.... Hold your breath".

However, this time... something was wrong! My stomach basically decided to call it quits! This wasn't an 'ordinary issue of stomach issues' - my stomach pretty much just up and quit!!!

I felt stuff regurgitating up my throat!! I felt myself being dragged out of the scanner... all the while trying desperately to hold my position as requested - hell, I didn't want to screw up the damned test and have to do it again!!!!!

As I was being mechanically pulled out of the scanner, I frantically waved my arms, and began pointing fingers into my mouth in the sign of "I'm gonna puke right now!"

I waited for back up. In fact, no back up came...

I ended up turning myself onto my side to mimic the "Recovery position" and proceeded to spew vomit onto the side of the scanner-bed and onto the floor. I vomited about 100 cc worth of my morning CT prep of Berry flavored Redi-Cat (*yuck!*)

Almost as soon as I was done puking, I began analyzing myself: "Ok, respiratory rate seems fine and other than the nasty shit I regurgitated as I was puking, my airway seems to be ok. My heart rate seems a little high, but we're not way up there yet. Ok... looks stable for now".

I leaned back/semi-sat up in that cat-scan-bed/stretched.... breathing through my mouth, retching the last of my vomit, trying to clear my nasal air passage...

"You ok, sir?

Where the HELL were you lady when I was puking?!! Do you realize that in the position I was in, I could have choked/aspirated in my own vomit??!!

"No I think I'm ok. Just have the residual effects of vomiting. I'm not nauseous. I'm actually pretty sure that I tolerated the Iodine IV injection just fine but when you asked me to "Breathe in and hold your breath" was then I started having a problem. I'm pretty sure it's gas related."

[I intend to follow this up with Radiology. It's fine and dandy that I am a young buck, trained in healthcare that was able to look after himself....

.... but what if I was an 85 year old vomiting on that scanner?!! Heck, no body rushed in! And when they did, no body bothered to turn me over to my side lest I aspirate my own vomitus! Me thinks a tad bit of training is due here!]

"Ok, Sir. Why don't we get you up and get you cleaned".

I pretty much proceed to get myself cleaned - including rinsing the highly irritating vomitus out of my nose *blech* *ugh*. Once I'm done, the tech lady (who was also the pre-ceptor earlier on), simply pulls my IV out and slaps and (inadequate) gauze dressing on top. I instantly put pressure on the spot, raise my hand about my head and politely ask for two strips of long 1 inch tape. A minute later, I bring my hand down and swiftly pressure tape my IV site dressing down.

"Ok Sir! You're free to go!"

... and that's it. No post procedure teaching. No "discharge instructions". No "discharge sheet". No 'basic' monitoring (like a short set of vitals signs. In fact, no one took my v/s either before or after) after a procedure like that - hell, especially after I showed an adverse (even if it maybe a "common") reaction!

Like I said, there are multiple issues with Radiology that I need to address....

Tuesday, September 18, 2007

"I just hurt all over! I feel like I'm going to die!"

Last week was a little rough at work - Friday was the pits. I had an incident with a patient in the wee hours of Saturday morning.

I didn't like the way it was handled.


Mr. Z is essentially a post-op Day #2 of a knee replacement. We've been having "issues" with his urine output - so PM shift inserts a Foley in him (around 2100 hrs). When I assess him at 2300 (that's when I pick him up from PM shift), he's alert, oriented, talking about his family and an otherwise pleasant gentleman. I see some clear urine in the Foley drainage bag - not much, but some. I figure it'll pick up soon.

While I was walking my rounds at the other end of the floor, I though I heard someone calling out for help. Part of me wanted to dismiss it saying "you're hearing things". But my gut thought otherwise ... and I respect what my gut tells me. Figuring it can't hurt to check; I quickly walk over to Z's room...

... where I find him half-naked, with his hips and legs (including that post-op knee!) off the bed and on the floor... and his upper body obeying the Law of Gravity by slowly inching its way downwards and towards the floor.

Dadgum it!

I do a mini-dash into his room, reach over across his bed, hook my elbows under his shoulder and hold him by his shoulders to prevent him from crashing onto the floor. Straining and grunting with effort (Mr. Z weighs about 200 lbs. I'm about 150. Right now, Mr. Z isn't co-operating and he isn't supporting his weight either i.e. he is "dead weight"). I quickly realize that I can't win this tug-of-war and with my knee, somehow manage to hit the call light button.

"May I help you?"
(with a strained voice) "It's Spook! I'm in room 80. I need some help here, NOW!"

That produces a determined response - I hear sprinting of shoes down the carpeted hall and a nurse and a tech burst into the room. They quickly recognize the gravity of the situation (no pun intended) and help me maneuver Mr. Z safely back into bed. Crisis (and not to mention the paperwork) averted - for now. Mr. Z claims he was trying to go to the bathroom to pee. I patient inform the patient that he has a Foley catheter and as such, he's already peeing and doesn't need to go to the bathroom. I emphasize the importance of calling us for any needs that he may have. He doesn't appear confused; he's still alert and oriented.

I check his Foley bag - there a little more urine in there than the last time I checked it. Not a whole lot more, but an increase no less. Just as a precaution, I do a bladder scan on him. The bladder scan is a nifty little ultra sound machine that lets us estimate how much urine is in the bladder. I repeat the scan thrice - each time, the machine bleats "000 ml". His bladder is essentially empty. Satisfied, I inform Mr. Z that because of the position of his urinary catheter and where it rests in his bladder (against his sphincter - the "valve" that controls voluntary urine flow) - he's going to have this "sensation" of being "full" and "needing to void". I tell him that this is normal and that he doesn't have to go to the bathroom - the catheter takes care of it for him. I once again, stress the need/importance of calling us for any needs he may have, make him comfortable and walk out. As a precaution, I douse the lights but leave the door open - just so I can hear better from his room.

I resume my rounds on my patients. I medicate as needed for pain, continue my assessments on my recent post-op patients (increase the O2 flow rate on one patient, irrigate an NG tube on another, do a wet-to-dry dressing change on a third patient), and get back to the nurses station to begin the arduous task of "chart checks" (night shift is assigned the duty of "chart checks" - essentially we go over a patient's chart and make sure everything is in order... that physician orders have been implemented/carried out, labs and other diagnostics have been ordered, check the ordered medications with the current one present on the Medication Administration Record {MAR} on the computer, note any changes in treatment plan for the oncoming shift etc.)

At Zero Dark Thirty [that's "Half past midnight" for you non-Army folks ;-)], the Tech (nursing assistant) comes and tells me that the patient is "quaking". She'd just done his vitals (vital signs) so I ask the obvious question:
"Well, is he co..."
But before I can finish she answers:
"No, he's not cold. His temp is 36.8. But Spook, his HR is 156. BP 156/80. Resp 34. Pulse ox was difficult to get since he was shaking and shivering like crazy but the probe told me 96% on room air. I put two extra blankets on him to warm him up before I came to see ya".

So I goes to see my patient. Mr. Z is in there quaking like a leaf in the wind. Despite my many attempts to gauge his pain, he constantly denies pain. And then I notice something queer - his arms are bent at the elbow and his hands are scrunched up to his chest. The hands are shaking violently, but his arms more or less lie in the same position. I ask Mr. Z to "extend" his arms at the elbow (i.e. straighten 'em out). He says "I can't"

You can't? Or you won't?

So I try to straighten 'em out. I have to apply a good bit of effort to do so! His arms seem to be "locked" in position - I am able to straighten 'em out, but boy, I really had to TRY! That concerns me - if I was less informed, I would jump and say "Tetany!" but I notice that his other muscles don't seem to be affected. His legs are mostly fine, his breathing... while fast, doesn't seem to be impaired. His heart sounds fast as well... but I can't detect an anomaly right away. To be on the safe side, I do a quick Neuro assessment (fearing a stroke - his BP and age certainly put him at risk for it) - but the neuro assessment check out ok too.

Now I'm puzzled - but at the same time, more "worried". My "gut" tells me "something's up buddy".

I look down at his Foley drainage bag - hmmmm, no real change in urine output. Actually, come to think of it, the output looks no different at all! I walk over to the store room; pick up a bottle of sterile saline, a piston pump and a drainage tray. Donning gloves, I proceed to "irrigate" the patient's Foley (disconnect drainage bag from catheter. Instill 30 cc of saline into bladder. Allow to drain. Repeat as desired). I notice that my irrigation brings about bloody urine with LOTS of clots. That is unexpected. I irrigate as much as I can (for over 20 minutes) and dislodge plenty of clots in the process. Finally, the urine starts clearing up. I stop irrigating and reattach the drainage bag.

Now what smartass?

And then, it hits me - patient is allergic to latex. Evening shift has somehow overlooked this fact and has installed a Foley which has Latex in it (as opposed to the silicone we use in such cases) - could this be the cause of bloody urine? Possibly, but if patient was allergic to latex - shouldn't I be seeing an anaphylactic/systemic reaction? What I'm seeing is not an anaphylactic reaction - but I'm hesitant to rule out a systemic reaction.

So, trusting my "gut" and for no real justifiable reason, I rouse the tech and tell her to get me a Data scope and monitor leads. I proceed to place Mr. Z on a limited, 3-lead ECG set up.

Time: 0137

Right away, I notice something "awkward". The monitor doesn't reveal anything earth-shattering or "critical" - but all the same, it looks "different". I'm uneasy - I know the patient has some cardiac history - but nothing significant. And yet, if I filter out his obvious tachycardia - his EKG still doesn't "look right" to me. Acting on my own initiative, I page RT (Respiratory Therapy) and have 'em come up and do a 12 lead EKG for me (on night shift, RT does all the 12 leads in the hospital). While RT is doing this, I double check the chart and make sure pt. has blood transfusion consent form signed and call Lab to verify is Mr. Z has been "Typed and Screened" (a procedure that tests a patient's blood and matches to his/her exact blood type). I tell lab I might need at least 2 units of PRBC (Packed Red Blood Cells).

Then, I page the Hospitalist (Hospitalists are Internal Medicine specialists who are assigned to patients who don't have a Primary Physician or have Primary Physician who is out of town or have no privileges at the hospital). I give her the full report and state my concerns. She says she'll be up soon.

10 minutes later, Hospitalist is on floor. By this time, RT has completed the 12 lead EKG and has printed a detailed strip. We go over patient's chart together, and I outline in detail my concerns as well as recent vital signs and patient behavior. Hospitalist goes in to observe patient.

10 minutes later, she returns. Orders are written:
Stat (meaning "immediate") Cardiac Enzymes (typically Troponin and CKMBs). Repeat in 6 hours. Call results of lab tests to Hospitalist.

"You think Mr. Z has had a heart attack?"
"Most likely, Spook. I'm not sure yet. He doesn't seem to be a typical heart attack patient; even his EKG seems to be non-critical. But I agree with your assessment - I'm also 'uneasy' over the way the patient is presenting. Gimme a call as soon as the lab values are back. And makes sure he is Typed and Screened."
"Already done Doc! I'll call you with the results"

I call Lab and tell them to send someone up pronto to draw the requested labs. I go in to check my patient - and while I'm assessing him, he utters the cardinal words - "Nurse. I don't know... but I just don't feel good.

"I just hurt all over! I feel like I'm going to die".

Hellloooo! "Mayday" call here!

I've learned to recognize and respect the "feeling of Doom" my patients sometimes tell me about. While my patient isn't exhibiting any of the "classical" heart trouble/attack "symptoms" of chest pain (often radiating), shortness of breath (while he is breathing fast, he doesn't complain of feeling out of breath) and an altered EKG - I'm still worried. His last comment of "I feel like I'm going to die" coupled with the Hospitalist's 'fear' just makes the case.

I look down to peek at the Foley drainage bag - no real out put since the last time I checked it. As I walk back to the nurse's station to check on the stat labs as ordered before, I tell the Tech to do a bladder scan on Mr. Z. The labs aren't awful but they don't look good either.. Both his Troponin and CKMB reveal a possible muscle injury. At about the same time, the Tech comes back to me and reports with wide eyes and the patient has over 900 cc in his bladder. I page the Hospitalist and tell her that lab results are back. She thanks me for the information and advises me to keep monitoring the patient.

I have 6 other patient's to attend to. Some have been calling out for over 20 minutes. It's 6 of one or half a dozen of the other. I request a peer, a nurse who works the float pool now... but who used to work ICU and actually used to be the Director of the ICU 6 years ago to go assess Mr. Z and the lack/low urine output. She declares that she is going to pull out the current catheter and try replacing it with a latex free silicone one.

I get busy attending to the needs of my other 6 patients. Some need pain medication. Some need anti-nausea medication. Some need to be repositioned in bed. I help the Tech with the ones who need help getting to the bathroom.

Time: 0330

My peer (the former ICU director) informs me of her inability to get a catheter into Mr. Z. She tried the three smallest catheters we have on the floor and she couldn't get in. Now, she's been an ICU nurse for over 15 years and has years of nursing experience before that. She looked me straight in the eye and said:

"Spook. You need to get him transferred off the floor, NOW. He needs critical care - and we can't give it to him on this floor." She'd checked his bladder residual via Bladder Scan after her last failed attempt to insert a catheter in him and it'd come back as over 1100 cc.

I swore under my breath and literally assaulted the phone. I called the Cardiologist on call and advised her of the situation. She asked me a dozen questions to which I responded the best I could with the information I had. She said she'd be on site within the hour.

Next, I called the Urologist on call. He rattled off a list of items he wanted readied and said he'd be on site within the hour as well.

Next, I called the Hospitalist. Informed her of the lab results.

"Oh wow! Mr. Z is having a heart attack. Please STAT page Cardiology. I'll come up soon to assess patient. Also start patient on prophylactic antibiotics - Zosyn prophylactic dosage IV every 6 hours and Vancomycin daily standard dosage IV every day per Hospitalist standing orders. Inform Cardio...."
(Cutting her off) "I've already talked to Dr. DO for Cardiology and Dr. NS for Urology and advised them both of the urgency of the situation. They will both be here within the hour."
"Oh good! Please monitor patient carefully. I'll be up in a few minutes.
"Will do, Doc!"

Next, I call the House Supe (House Supervisor) TA (a Registered Nurse) and let her know of the meltdown on the floor. She lets out a silent groan and asks me "what's the plan?"
"DO and NS are coming over to work on the patient. I suspect he will soon be moved to the Cath Lab. TA, I could really use some help. I'm juggling 7 patients here."
"Ok, I'll be up soon and I'll bring along EM from ICU"

EM is an ICU nurse. ICU nurses, along with RT respond to a "rapid response" on the floors. Though I have not "called" a Rapid Response on the patient - given the situation, it's understood that this is warranted. RT is already on the floor.
I've worked with EM and TA before - they're swell. As soon as I'm done talking to them, I call the Cardiologist again and request that the patient be transferred down to the ICU or the Cath Lab - reason being that folks down there are more attuned to crises of these sort, have more training and also more "leeway" in terms of physician orders to deal with it. Cardiologist refused - stating that she needs to assess patient before allowing transfer because she didn't know if patient needed to go to Cath Lab right away or if transfer to ICU would be appropriate for the moment. I could understand her PoV... but at the same time, I cursed it. Because I knew that the minute she would walk onto the floor, she'd ask me a million and half questions - and a lot of them I would not be answer because I simply didn't have the authority to order those tests or carry out those interventions. A nurse in the ICU or Cath Lab could have - but I couldn't. I lacked the "standing orders" protocol and authority.

With the calls done, I decide to prep the patient's chart - transfer to a "different unit" requires some amount of paperwork - thanks to "The Joint Commission" (cue reverential music). Mostly unnecessary BS that actually eats up my (and more importantly the patient's) vital time... but who am I, a lowly staff nurse on the floor to argue with the rules laid down by the demi-gods in JCAHO?

While I'm prepping the chart, I tell the Tech to get me a fresh set of vital signs on the patient. She responds and promptly reports the news: HR: 110, BP: 150/100, resp rate: 28, Pulse ox: 90%

Not good. I grit my teeth...

Time: 0415

... and as I'm doing do, the Urologist walks onto the floor. I ask my fellow nurse on the floor (and the tech) to cover my side of the floor while I assisted the Urologist.

Then, I gather the equipment and walk into the patient's room to assist. Urologist administers local anesthesia and proceeds to brutally ream out the man's urethra (penis). But he does get a good sized latex free, silicone catheter into him and immediately drains over 1100 cc of urine from Mr. Z's bladder. Near the end of this procedure, the House Supe and the ICU nurse arrive on the floor.

I feel a degree of relief - I have back up now. The ICU nurse immediately proceeds to take a quick report on the patient from me, and then says "Spook, I know you have 6 other patients to look after. Take care of them; I've got Mr. Z under control here". She proceeds to diligently monitor the patient with help from the House Supe. I place a call to the patient's wife and inform her of the events. She is distraught, as expected, but informs me that she'll be over as soon as she can wake up her son to take her to the Hospital (she's disabled).

Time 0445:

The Cardiologist walks onto the floor. Converses briefly with the Urology. Then turns to me and begins a barrage of questions - many of which I am unable to answer. EM, the ICU nurse steps up and says "Well, it's hard for staff nurses on a regular floor to do these things. They usually have more than 6 patients to worry about and their freedom of action is restricted by the lack of standing orders in case of emergencies. Do you still want to move the patient off the floor?"

Cardiologist softens her stance a bit. "No, I still have to see the patient. Let's go".
I turn to EM and she winks at me with a smile before accompanying Cardiologist to see the patient. I'm grateful - while I do feel like a blubbering idiot for not knowing everything the Cardiologist asked of me, EM showed that it wasn't entirely my fault. That helps... a little.

Meanwhile, it's almost 0515. Time for I/O, morning meds, blood glucose checks and insulin administration, changing IV bags and PCA pumps, helping patients to the bathroom.

While all that is going on, I'm frequently interrupted by the nurses/doctors hovering over Mr. Z. Pharmacy has sent up the Abx ordered by the Hospitalist for Mr. Z. I hand them over to EM.
Then it occurs to me that I have not charted on Mr. Z for a while now and that in all possibility, he is going to be transferred off the floor! I hurriedly jot down the Physician orders I've recd. over night for Mr. Z and then sign them off. Also, as a courtesy, I print of a Med Reconciliation List and other needed documents [a "The Joint Commission" (cue reverential music) requirement] and hurriedly place them in the chart.

By the time AM shift arrives on the floor - Mr. Z has mostly been stabilized and is just awaiting swift transfer to the Cath Lab. I'm tying up loose ends and paperwork... while simultaneously trying to deal with my 6 other patients - who are all due morning antibiotics, I/O, pain medication and toileting. Cath Lab folks are now in Mr. Z's room - TA and EM will handle transport for me (standard protocol)... and I'm grateful for that. The Cardiologist has managed to obtain consent for possible procedures. Lab has blood work confirmed.

Charge nurse walks onto floor and observes flurry of activity and just shakes her head.
I am unable to tape report for the next shift and thus must give verbal. Some of the nurses on AM shift roll their eyes, as if stating "He hasn't taped report yet! That is so inconvenient!!" Some nurses on AM shift instantly piss me off by asking inane, dumbass questions they don't need to ask (because they can look it up for themselves). One of the nurses on AM shift grouses over the fact that I haven't discontinued a Foley catheter on a patient - I thought it was incredibly rude, condescending and short sighted on her behalf and I'm tempted to tell her that I had "7 patients all to myself with one of them having an active heart attack" but I bite my tongue and say nothing. It's pointless - day shift has never had to deal with short staffing.

I finish report just as they are wheeling Mr. Z off the floor. I thank TA and EM again for their help and assistance - truly, I wouldn't have been able to do 1/10th of what I did without their help.

I haven't eaten in over 14 hours. I haven't even taken a bathroom break to piss in my entire shift. I quietly go and relieve myself, then sit down to chart.
After 3 hours of charting at the end of my shift, I tiredly walk to the elevators, punch out and leave for home.
Fighting sleep the entire way, I drive home in one piece and collapse in bed.

Only for 3 hours though. For I'm scheduled back for that night.

Mr. Z ended up getting a quadruple bypass surgery. He's still in the Cardio Vascular Care Unit as I type this....

JCAHO and "safety"

My hospital is still waiting for "The Joint Commission" (cue reverential music) demi-gods to make their interrogation inspection and pronounce summary judgment announce the results of the survey.

This isn't the first time I've voiced disdain and ire about "The Joint Commission" (cue reverential music).

But while I rant in my crude, unsophisticated fashion; Dr. Whitecoat does the same... only with panache. Head on over to Dr. Whitecoat and read this little gem.

Just be sure you're not eating/drinking anything lest you do a spit-take...

I firmly believe ERnursey is right when she says this about JCAHO:
They are like any governmental entity, they make stuff up that makes no sense in the quest to ensure their own continued existence.

Couldn't agree more.

Saturday, September 15, 2007

Proverbial "Week from Hell"

Holy crud!

I haven't felt this tired since they made us do forced marches in the Army with a full pack and ammo load over beach sand. My legs feel like they've been hammered with a baseball bat. My brain is quite literally numb. More like mush.


The entire freaking hospital has been packed to the gills all week. I think we had ONE bed (each) free in the Cath Lab and the ICU. That's it. Every other unit was packed. I was seeing 10 patients a night - 2 admits, 2 discharges, 2 routines and usually 4 post-ops. I think we had a code almost every night on the floor. Every body is in a foul, evil mood.

I just want to crawl into bed and sleep for a week. But I'd already volunteered for an extra shift tonight.

Which will be my 5th 12 hour shift in a row. *groan*

Note to self: Next time charge nurse drips sugar and honey when asking you to volunteer for an extra shift - don't be an idiot and say "Yes!" without checking your schedule first!

I feel like a world class moron. At that time, a part of my brain was probably telling me "I smells a rat here" but I was probably too dumb (or too tired. Lack of sleep has wondrous effects on your judgement) to notice.

Meh! So that's where I've been all friggin' week. The only good thing was that I finally got my tickets confirmed for my vacation and sent the dates to my boss. Charge nurses aren't happy (though I'm scheduled for only 3 12s a week... I work an extra shift or two almost on a routine basis), because now they're gonna have to scramble like mad to fill my slots.

I don't care. I haven't had a vacation in over 4 years now. I haven't been home in over 3 years. I need a break or I'm going to burn out...

Tuesday, September 11, 2007

Today is the day...

"A day which will live in infamy" for my generation.

I often refrain from making comments about today... as a reflection upon "the day".
Because "The Day" in question holds a mixed bag for me.

I remember coming home in time to see my parents watching TV. The scene seemed right out of a Hollywood disaster flick. Smoke billowing out of a skyscraper. Excited voices on TV. My first thought was "Huh. Wonder what the new movie is going to be about..."

... and then I watched in fascination... as a plane (the second airliner) slammed into the Second Tower.

And then I realised, to my utter horror, that I wasn't watching 'E! Entertainment' but 'CNN'.

This was no disaster flick. This was "real life".
I wish I could erase from my mind and memory those innocents jumping from the burning towers to their sure deaths....

I was traumatised. I was shocked. I was numb. I was angry. I was upset. I was belligerent. I was enraged. I was weeping with hurt and sorrow.

All and once.

I called one of my best friends. I just couldn't bring myself to wish her a Happy Birthday... all I said, with anguish was : "Turn on your TV. CNN. " Then I put the receiver down. I could barely speak.

I've lost close friends to terrorism. I've lost a "brother" fighting that idea and the folks who preach that ideology.

Though I knew no one who lost their lives that tragic day, I was deeply wounded.
The murder of innocents rarely ever makes sense to me.

But, the aftermath of "The Day" has and still affects me today - as I said, "The Day" is a mixed bag to me.

For the first two years following that tragedy, I was careful when I ventured outside. On the way to campus. On the way to the gas station. On the way to the grocery store.

Folks were quick to judge me. Hurl epithets. Rain abuses. Step in my way and threaten bodily harm and worse. "Don't bomb my country!" was a common abuse hurled my way. As were "Sand nigger", "Camel jockey", "Towel head", "Fucking Ayrab", "I'm going to fucking kill you and your Momma you rag head mother fucker"... among others.

I'm not Muslim, heck I don't subscribe to any particular religious denomination (my thoughts and concerns about a god are my private business. As I think is the case with every one else). I'm not of Middle Eastern descent. I don't and have never condoned the killing of innocents - no matter what the cause.

But my 'tanned appearance' was enough to provoke some folks.

I was distraught. I hurt. I was bewildered and at a loss as to what to make of it all.

I was in Oklahoma City when McVeigh hit Alfred P Murrah and slaughtered those hundreds. I was barely in 7th grade... and I went with a friend, to pay my respects to those who lost their lives in that tragedy. No one said a word to me then... rather some folks welcomed me.

That was then. This is now.

This doesn't detract from the horrific tragedy that was September 11, 2001. Just as it doesn't distract from April 19th, 1995.

I mourn the loss of 9/11.
I mourn the loss of 4/19.
Just as I mourn the loss of my "brother".

Rest in peace, all ye who lost your lives as consequence of senseless violence.
May we yet learn to grow out of it all.

- Spook

Wednesday, September 5, 2007

Why I do what I do...

A very thought provoking entry on Float Pool RN's blog prompted me to post the following.

It isn't exactly something new.... but it does give a glimpse into my past.... and possibly my future.

A glimpse of why I do what I do...

I was a student nurse.

Working our first peds rotation at Children's Hospital. This rotation was always high in demand - I picked it for no other reason because I wanted to figure what peds would be like [and definitely for the instructor. I loved her to pieces - she was just completely awesome! :-)]

Up until that time - I really didn't have an idea of what I wanted to do once I got done with school, yeah? I had some vague ideas of getting into some kind of critical care at some point in time.

Anyways, this was my last week of clinicals. Up until that point, the whole experience had been a roller coaster. We had some really sick kids who coded and didn't make it and also some sick kids who got well and went home. Peds was starting to "affect me".

But my last patient was the cake.

She was in for a double ureter re-implant. I was assigned to her the day after she'd had the surgery. She was this really sweet 6 year old girl.

Absolutely the bravest person I've met in ages.

Ne'er a cry or whimper. She was absolutely delightful - never asked for pain meds unless it really really really hurt. Despite my assurances that it was ok to ask for something to make the pain go away - she never did.

We were assigned 8 hour shifts and I went about it my own way - general checks/assessments q2h, checking her tubes (2 JPs and 1 SP) and drains Qh. Meds as ordered. Gave her baths. Linen change. Played "chance" and some other games - heck, even played with her stuffed toys! LOL

The only thing she wanted to know was when could she get outta bed - because she wanted to go for a ride in the toy cart :-)! She asked me all kinds of questions, from her body, her condition, to me, my background etc.

So anyways, I go back the next day. And I'm assigned to her again (mildly surprising. I'm the only guy in our batch on the floor who has constantly been reassigned to the same patients. I didn't find out till the end of our rotation that this was done at patients request - they'd liked me and the job I did so they wanted me again!)

So I walk into the room to do morning assessments and while checking her BP I could see she was trying hard not to giggle. So I turn my back to get her meds - and I can see her squirming in her bed. So I ask her what's up.

She asks me to close my eyes, she has a surprise for me.

I close my eyes and in my hands, she places this little card. Made in green paper.

It said "To Spook

Thank you for taking good care of me


Her Mom explained that she'd spent 4 hours, painstakingly drawing with her right hand (she's a southpaw but her left hand was boarded with an IV board).

My vision was blurry. I don't cry easy but I did feel that one tear drop down my cheek. I gave the kid a warm, heartfelt hug.

I'd been having a horrible week to the point that I even came to doubt myself. I was wondering if I'd bitten off more than I could chew. Debt was killing me. Working two jobs just to barely keep my head above the water, sleeping about 4 hours a night at best etc. etc.

That card and her smile when she gave it to me changed all that.

That was when I decided - right then and there - that it was all worth it. That's when I decided that when I graduated, I was going to do peds. Life or death, sickness, suffering or recovery; I just knew right then that I'd be doing it with kids.

I'm still workin' on that goal...

Someone please tell me how this makes any sense...

Example 1 -

Unit census: 30 patients.
Staffing grid allocation: 5 nurses, 2 nursing techs (assistants).

Ergo: 6 patients to each nurse. 1 tech assisting.

Example 2 -
Unit census: 12 patients.
Staffing grid allocation: 2 nurses. Zero techs.

Ergo: 6 patients to each nurse. No techs assisting.

Why the drop in staffing? The patient:nurse ratio hasn't changed.
Do you think it makes any difference to me if there are 30 patients on the floor or 12 - I'm still juggling 6 patients!! If it doesn't make a whit of a difference to me, then why am I expected to "make do" with no assistants when there are only 12 patients? Does having "12 patients" somehow = "less work than" having 30 patients?

They are called "Nursing assistants" - not "floor assistants" - for a reason.

Don't get me wrong - I'm not trying to "avoid" work here. Merely wanting to point out that all management can speak about is "patient satisfaction" and "customer service". Does their rhetoric match the implemented plan?

I don't think so.

I've asked this question at work - mostly my peers/colleagues. 98% of them pretty much shrugged their shoulders, implying that it was a rule set in stone.

I don't think it is. All I need to do, is compile evidence.
I'm working on some of my own (the simplest being 'average response time to call lights').

I invite suggestions and ideas from y'all...

Monday, September 3, 2007

Staffing again...

ER Tech Dude makes a critical point about staffing in hospitals.

So I say let's spread out the overcrowding with each unit absorbing a portion of the ED overcrowding. Nurse patient ratios aren't a valid excuse when it comes to refusing a patient admit to the floor, the ED nurse patient ratios are out of proportion daily. What's acceptable for one department should be acceptable to all departments.

Hospital administration has to stop sending nurses home mid-shift because the patient population has fallen 1 patient under the arbitrary ratio number. They also have to be willing to call in additional staff or use a staffing agency when capacity is reached.

Other departments don't care about ED overcrowding not because they're uncaring, it's because as long as the patients can be housed in the ED, it's not their problem.

The solution to ED overcrowding is to get rid of the crowd. Admit and move the patient to the medical floor and watch how fast beds are found.

One flaw with the proposition is that regular floors aren't equipped the way EDs are. Try running a code on a crashing patient on a medical floor and you'll know what I'm talking about. Nurses and equipments on medical floors simply aren't equipped to deal with potential problems the way the ED is.

I'm not saying what's happening is right - having a "stuffed to the gills" ED doesn't sound safe to me either. I'm just trying to provide a different perspective.

At my hospital, my unit typically takes all overflows - even though we are the Surgical/Ortho floor. I've seen everybody up here - Medical, Tele, Gyne, Pulmonary, Oncology, Uro, Neuro ... hell, even the occasional peds patient (even though none of us up here are PALS certified).

The problem, I submit, is the recent shift in hospital admin views about unit census. The current theory is that to stay out of the red, units should be staffed as close to being "full" as possible. They figure this to be efficient - hence why they closed the Medical/Oncology unit in my hospital. Now not only do we see their medical patients, we see their oncology patients too. And on top of that, we take their overflow as well.

We nurses, of course, think this is stupid. "A nurse is a nurse is a nurse" is a fallacy - when you cram different patient populations in the same unit without adequate staff training to take care of them, patient outcome is going to suffer. A medical nurse cannot take care of my post-op knee any better than I can take care of her pneumonia patient.

Besides it being unsafe and all...

I do concede the point that unit managers need to stop judging scenarios based on some arbitrary "Staffing ratio" number. But this again, is a two sided story - those "numbers" are set by admin. Once again, admin wants to eat it's cake and have it too - they want to increase efficiency but look with evil eyes everytime staffing goes "over the limit".

Then again, this isn't exactly something new....

All patients don't come to the hospital through the ER. Many are electives. Some are direct admits. Floor nurses see patient dumping too.

ER Tech Dude, you have my sympathy and support. Let us see if we can change the numbers game...