A Day in the life

Whoooooooooooooooa!

What a WEEK!

Tuesday noc (noc=night)- 16 hour shift. 7 patients (6 post-ops + one confused/agitated, non-restrained patient). One tech.
Wednesday noc - 16 hour shift. 7 patients (3 post ops + 2 admits + same confused dude). NO TECH!
Thursday noc - 16 hour shift. 7 patients (5 post ops + 1 admit + still same old confused dude). One tech (who is so useless, might as well be considered NO tech!)
Friday noc - 12 hour shift (I was scheduled for an 8). 6 patients (5 post ops + confused and now "combative" dude). NO TECH!


And to top it all - we have no "charge nurse" for night shifts.

So.

Anyway.

Tuesday night was the first time the Day Shift charge nurse (we have charge nurses from 7a-7p) handed me the "charge nurse phone and keys". Floor nurses carry pagers and narc keys ("narc keys" are used to unlock PCA (Patient Controlled Analgesia = patients get to push a button when they think they need some pain medication and a pump set up within controlled parameters delivers medication as needed) pumps. Charge nurses carry a phone accessible by anyone and from anywhere in the hospital and special set of keys (for elevators, supply cabinets, sure med, crash cart alarm unlock etc).

Turned out to be a good thing too. Because we ended up having to call a "Rapid response" (instantly call upon an RT [Respiratory Therapist] and an ICU nurse with standing orders and leeway to treat patients) on a freshly admitted patient from PACU [Post Anesthesia Care Unit ... where folks who've just had surgery are stabilized before being sent up to the surgical floor] - who ended up becoming "unresponsive" just as she was being wheeled out the elevator to the floor.

Wait, it gets better. I marched over to assess situation. It was tense, but we were handling it... but I had an uneasy feeling about the whole deal. Clinically, the patient was in "distress" but my gut was sending me all kinds of funky signals.

So now, of course; patient chooses to slip into "unresponsive to pain" status....
Lovely!

R-Triple-D! {Army talk for "Really-Deep-Doo-Doo}.

Called a Code Blue. Ran over and dragged the damned crash cart all the way across the floor and by the time I reached the floor, RT and the ER doc were there. Hung around to document till House Supervisor showed up (poor girl, was already tied up with a Rapid Response on medical floor!) Handed over charge to her and then raced back to pass meds on my post-op patients (Antibitiocs, HS {HS= Latin for 'Hora Somni' = bedtime} meds, Accuchecks {checks blood sugars} and HS insulin) all the while fretting about my confused dude. Mercifully, he was confused and naked but apparently had decided to stay put in bed for the moment.

By the time I got done with all this, my code patient had been successfully intubated and revived. I arrived just in time to see her being wheeled down to ICU.

Naturally - this left me playing catch up all night long. I don't know how I managed, but I managed to stay on top of patient care (while neglecting charting) till I could tape report.
Ohhh, did I mention that I had to go to a staff meeting at 0730 in the morning? And at this TWO HOUR (#*&&*^Y$) staff meeting, we were literally "read" power point slides. What a colossal, monstrous waste of time! Did they really think we couldn't read from handouts? What is this, grade school??!! Here I am, atleast 2 hours of charting ahead of me, wasting time listening to this nonsense! &*!^&$@!#!

I managed to stay awake through charting and somehow drove home. I don't remember what I ate (or if I ate at all! I was beat!) but I do remember that I couldn't sleep - damned lawn mowers kept me awake!

I finally managed to sleep 3 hours - and I was back that night.
Other than the fact that there was no "code" or "staff meeting", my night was a repeat of the night before. Too many sick patients, not enough staff.

Once again, dragged myself home.

Thursday night, post 4 hours of sleep. Not entirely bad - except for one of my post op patients who has some kind of weird fixation with his Codeine allergy. Pt. is a fresh Total Knee Artho (total joint replacement of the knee), with a measly Femoral block in place running Ropivacaine 0.2% @ 10/hr. Naturally, he starts complaining of pain into the noc. I try to convince him to take the MSO4 (Morphine) PCA as ordered. He refused - along with refusing the Dilaudid, Fentanyl and Toradol. He became infuriated with the "scheduled" med times and proceeded to fling a book across the room in anger, called me an "good for nothing, idiot SOB who doesn't know a thing in the world", threatened to leave AMA and/or sue/complain about the hospital and his "substandard level of care".

He wasn't thinking rationally nor clearly. He wasn't altered mentally in anyway - but it was patently obvious he had received little to no pre-surgical counseling (and given his surgeon, I was not surprised!) or he was a general insufferable idiot "know it all" (or a combination of the two).

I was close to blowing a fuse myself, but somehow maintained control, managed to calm the pt. He ended up calling the surgeon's office in the morning and lodging a personal complaint! Long story short, I made sure I documented the heck out of that incident and made sure I had collaborating evidence of my numerous attempts at making him "try" alternative medication for pain control (along with supporting statements from other floor nurses).

During all this time, did I mention the fact that I had 6 other patients? Including Mr. ConfusedandIwouldlovetoclimbouttabed ? Who did, end up rupturing one of the lines in his dual lumen PICC thanks to his constant meddling and poking?

Dragged myself home. Got about 6 hours sleep. Back on Friday noc.
Thankfully had "just" six patients. 3 post-ops and 3 others. One tech to stay with mr. confused.... which meant no tech for the floor. But I didn't care. Had to go down to the CCU (Critical Care Unit) and insert a foley in a patient and set up a CBI because apparently none of the nurses there (nor the house supe(ervisor)!) knew how to set up a foley with CBI (links to a PDF document) infusion! Most bizzare!


That's about my story of the week. Just had to get it off the chest.
Been super stressful.


Oh - and work wanted me to consider "coming in for 4 hours to cover 7p-11p". I practically told them to 'shove it' (politely of course!)

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.