What a Mess!

Nursing can be a very messy career.  It is not unusual to leave after a twelve hour shift, with mystery stains on your scrubs or shoes.  Or to see things come from patients that you have never seen before.  It is also likely you may see a scene that you feel should be included in a horror movie just because it would put some of the bloody scenes from Hollywood to shame. 

I was caring for a patient one night who was complaining of severe abdominal distress.  He could not tell me what exactly was wrong.  Just that there was something weird with his stomach.  I asked him if he was nauseous or if it was more pain, but he said he couldn’t tell.  He said it just felt really funny and he knew something wasn’t right.  I gave him some Zofran to help settle his stomach.  Upon assessment I noticed that the stomach did look and feel quite distended.  Now this patient was a liver patient and abdominal distention is common with this type of patient, however something just didn’t feel right about the whole situation.  So I did the only thing I knew to do.  I called the doctor and asked him to come see the patient.  Of course, the doctor told me he was stuck in the ER admitting patients but he would be up there as soon as he could.  (In other words I just got nicely brushed off and he didn’t think it was any concern).  The next thing I knew the patient was vomiting.  I was dreading going in the room, because vomit and I do not mix very well.  I am a sympathetic vomiter and I did not see this ending well for either one of us. 

However, I sucked it up and went in to care for my patient.  As I entered the room, I noticed his vomit did not look right (yes, only nurses and doctors would say something like that and actually pay attention to that).  It was really dark and looked like coffee grounds.  This is a sign of a GI bleed, so I was worried and called the doctor back.  He was still not very concerned at this time and told me to just monitor the patient.  This was fine until the patient just kept getting worse and worse.  I finally called the doctor back and told him that he really needed to come see the patient because it was just getting worse.  I finally got the doctor to agree, only to have him show up on the floor and stand in the hallway and talk on the phone for the next 45 minutes while I was trying to figure out what he wanted to do about the patient.  By this time his abdomen had doubled in size and he was still vomiting what appeared to be blood. 

Finally the doctor got off the phone and ordered his labs to be drawn to check his blood cell count.  After a minute of thinking about it, he then also ordered a Nasogastric tube to be placed and turned to suction to remove some of the blood from the abdominal cavity. 

As I was preparing to place the tube, my fellow co-worker came to assist.  We finished preparing and began to place the tube, but discovered we were going to have more trouble than we should have.  The patient had a deviated septum which means we could only use one nostril.  The first attempt the tube coiled up instead of going straight down the throat.  A second attempt was just as unsuccessful.  Instead of trying and failing a third time, I did the only thing I could think of…I went and asked another nurse to help. 

She also failed the first time, but her second time was a little bit successful, however as she was finishing, the patient began to cough and gag.  Of course as he coughed and gagged, he began to spit up large blood clots, and large amounts of blood.  His coughing was so forceful, blood ended up on the wall across from his bed.  There was blood everywhere.  Seriously, it looked like a scene that should belong in Exorcist or some other movie.  It was a mess and where he was coughing so much the tube would not advance.  We had to pull it out.  Thankfully Rapid response was able to get the tube placed and suction was set up.  Although the patient felt horrible for the next few days he was much better within a few days.    

Where Do I Work Again?

So last night at work, I began to realize that sometimes nursing equates working in a hotel...not just any hotel but obviously the Marriott hotel. 
The night started out rough because we were short one tech with lots of busy patients.  The call lights were unending.  One would ring and of course five others would go off at the same time...that in itself was unbearable, but then it got worse.
One of my patients was a sweet older man who had been diagnosed with liver cancer.  Up until five months ago he had been running 3 miles, lifting weights, and swimming 100 laps a day.  Then he lost 40 lbs in three months and became very weak.  His primary doctor had urged him to come to the hospital ASAP, but he refused until after Thanksgiving so he could be with his family.
When I admitted him, I remember thinking...this is one patient I would take home with me...he's so sweet and adorable.  His family at the bedside, two sons, were very nice and polite.  They stayed long enough to answer any questions and to ensure their father settled in for the night.  (The first night with this patient was a breeze, he slept all night and didn't need a thing...my favorite patients).
This night his two daughters were at his bedside.  And I could tell from the beginning they were going to make sure my night was a long difficult one.  The first daughter introduced herself. "I'm Dr. _________  and I want to talk about the plan of care."  I politely answered all of her questions (even though some of them I had to go find the answers).  Next she demanded that his zofran be increased to 4mg every 4 hrs instead of every 6 hrs.  I told her I would have to call the Dr but I would go ahead and bring in the dose that was due.  She rudely commented, "Yeah you should do that".
I got his zofran adjusted and brought in his dose.  When I got into the room and offered it to the patient, he refused it.  The daughters of course jumped all over him to take it...when he still refused, I told him that it was okay and i didn't have to give it to him...well let me tell you...the daughters definately did not like that..."He does need it and you WILL give it to him right now!"  I calmly explained that I could not give it to him unless he was the one who said he needed it.  The daughter looked at him and finally convinced him to take the med.
As soon as I left the room, I felt the daughter on my heels.  "I am his legal Power of Attorney and I want to read the doctor's notes tonight right now!"  I explained to her that I was not able to give those to her and she would have to go to medical record with the Power of Attorney paper.  She was definately not happy about that.
I managed to make it three steps away when she started asking me about a private room and if there was anyway they could have one... I explained that I would put in the order, but it was not a guarantee that they would get one...but that I would do what I could. 
What she said next just totally astounded me.  "Can we put another sleeping chair in the room and shove the other patients bed up against the wall?"  WHAT!!!!!
"Uhm...no we can't do that...but i can either get you a list of hotels nearby or I can make a sleeper chair for you in the waiting room".  After printing off the list of hotels, she decided that none of them were good enough for her, and she wanted the waiting room (Uhm...if the hotels aren't good enough...you choose the waiting room...what????)
The tech and I went and found a reclining chair and rearranged the waiting room to make up the bed.  As she enters the room, she says "No No, can you move the chair so I can see the tv, and then tilt the tv so I can see it better".  (Okay at this point I was having a really hard time in not saying something nasty especially since she was still running around barefoot, after i gave her some socks...I mean really who does that!!!!).
I thought that once she fell asleep it would be better, but no she decided she was going to stay up all night and make demand after demand.  Made for a very long night.
When I returned the next night...this patient was no longer there, but the stories the day nurses told me...complaining about meal trays, dumping meal trays onto the OTHER patient in the room, demanding to see the dr right now...then complaining about the meal tray to her, demanding a private room an hour ago, and then of course just being rather demanding of the techs and nurses.
So to close this out...I'm gonna still a quote from one of my work friends "I pulled into what I thought was the hospital parking garage tonight but apparently to some people, it's the Marriott with an all night buffet".

Do Something!!!! Please!!!!

I know that I have written quite a few articles on patients coding or declining...but unfortunately that is a sad part of the job.  (This time it didn't happen on my wing or any of my patients...no one can blame "Crash" this time).
It was 0715 one morning.  I had to take a quick break from report to grab a paper towel.  As I entered the hallway, I saw two residents enter the room of a patient on the wing straight across from mine.  Within 10 secs, I saw the Assistance please light go off.  I quickly yelled at my techs and the other nurses on my wing and we took off running.  One of the techs stopped to grab the crash cart along the way.  As I went running pass the clerk's desk I told her to call a code.  As we entered the room, we saw the patient laying in the bed with a nasty bluish gray color.  He wasn't breathing and the continuous pulse ox was not picking up a pulse or an O2 sat.  The residents were just standing there with a scared look on their faces.
I pretty much jumped onto the bed and the patient and started chest compressions.  The other nurse quickly checked for a pulse, and went to grab the ambu bag.  Of course there was no ambu bag or suction set up in the room.  Two other nurses quickly started looking for a vein to put in an 18 gauge IV.
The whole time, we are all looking at each other wondering where Rapid response, respirtory and other doctors were.  Since I work on an acute care floor, we are not allowed to push medications during a code, either the doctors or rapid can do that...and since the two residents in the room, were not responding to our yells to do something...we were kinda stuck in a hard spot.
We continued chest compressions, ambu bagging (we had to run and find one), started three IVs (three nurses all at once got them at once) and freaking out for fifteen minutes before everyone else started showing up.  (Although from the moment I did my first chest compression, I knew the patient was not going to make it, due to all the fluid that was coming out of his nose, mouth, and ears).
Once rapid showed up and took control they were able to get the residents into motion but only by telling them step by step directions.  We continued coding the patient for another 30 minutes, because no one wanted to admit this was one that we could not save.  However, the attending eventually called it and night shift ended their shift on a depressing note.   It's definitely a difficult thing when we are reminded that sometimes there is nothing we can do, no matter how hard we try.

Just Another Night

Oh the things my co-workers can tease me for…I swear…so the newest  joke on me is…I have a thing for old men.  Well at least that’s what my co-workers say after tonight…the night I will almost definitely never forget. 
One of my patients tonight (actually one of my preceptee’s patients) was an adorable 88 year old who was here for cystocele surgery.  She was adorable…as was her husband, who was so attentive he never left her side. 
The night started off busy with two direct admits back to back (with one of them being a surprise because the day nurse forgot to give us report so we had no idea he was coming until he just showed up).  But we made it a point to check on the other patient every hour. 
She had a catheter in place and was on a PCA pump (now really, this was a disaster just waiting to happen but you know that’s the fun in it, I guess). 
We managed to handle the two direct admits pretty well which is actually harder to do then it sounds…and by midnight we were pretty much caught up and in a good spot.  But then trouble began.
The first sign of trouble occurred at about 0200.  When I checked on the patient she was wide awake, her husband sleeping in the recliner next to the bed.  She gave me a really strange look, and if I would have only known what that look meant…I might have just walked right back out of the room without bothering her. 
“Are you having any pain?”  Well of course her response was not what I expected.  “Why the hell would I be in pain!!!!!???”  “Um…because you just…um…had surgery…and I was just um…just wondering”
“No, I’m not in pain…but I need to use the bathroom…right now!!!!”
I did a quick check of the catheter, which appeared to be draining, and I’m sure I sounded pretty confused, “You have a catheter, do you feel like you need to urinate?” 
“Umm…No,…I need to do the other thing.  You know the stinky thing”.  I suggested maybe using a bedpan or even a bedside commode, but the patient was not going to have any of that…”Young lady…I am not too old to go to the bathroom…Now help me get there.” 
I assisted her to the bathroom…regretting that decision from the moment I got her up…she was very unbalanced on her feet, and about took us both to the ground a few times before we made it.  Not the brightest idea I’ve ever had. 
The second I got her to the toilet and she sat down…she yelled “GET OUT!!! NOW!!!”
Now I’m all about giving privacy…but when it comes to unsteady 88 year old women, especially one on narcotics, unsupervised in the bathroom…I’m not that stupid.  Then the IV pump at the bedside started to go off…so I did the only thing I could think of.  I told her to stay sitting,  closed the door just enough to give privacy and ran to the bedside to fix the pump.  Suddenly, I heard the bathroom door slam.  I quickly turned to the husband.  “Please tell me that was you?!”
He shook his head.
I ran to the door and tried to turn the handle.  It was locked!!  Of course…Wait…Our bathroom doors lock????!!!!  “Sweetie are you okay?”
Nothing, it was completely quiet in the bathroom.  So I acted like a little child.  I knocked on the door, when that didn’t work…I pounded on the door…and when that didn’t work…I pounded on the door and screamed her name…still NOTHING. 
All my yelling brought about the rest of my co-workers.  When they saw what was going on…they all looked at me and said…”The bathroom doors lock???!!!”  I tried to stay calm…but man I was about ready to kill them… “Uh no they don’t lock…I’m just standing here like an idiot beating up the door!”
I started to do something as a nurse you shouldn’t ever do…I started to panic…and it takes a lot to make me panic.
I dropped to the floor and laid my face on the cold, germ-infested floor.  I could see a gown, but nothing else on the floor…well that’s good…she hasn’t fallen at least…has she!!!!???
I called environmental services and security.  Minutes later, they showed up and looked at me and said… “I didn’t know those doors locked”. 
Oh great…now what in the world am I supposed to do.  I grabbed my scissors and attempted what I later found out looked really funny.  I attempted to pick the lock…of course my scissors didn’t work. 
As I’m trying to play petty theft, I start to hear the husband going crazy.  “Helen…I mean it you need to come back here.  You need to leave those tigers alone!!! Now I said come here.  Those bears are going to get you and then you will be sorry!” 
Uhm…What in the world?
The husband is pacing around the room…when we try to reorient him, he looks at me.  “Who the blast are you…and what did you do with my pickle?”
(Now any other time, this would have been pretty entertaining…but at that moment…I could have strangled him and everyone else)
The tech helped him over to the bed to sit down.  I returned to pounding on the door and screaming my patient’s name.  Of course, still no answer.   I just knew that my patient was on the other side of that door…dead. 
The husband was on the bed trying to punch the tech in the head…and was cussing and swearing up a storm at him.  And of course, all of the other patients were going crazy on their call bells, IV pumps were beeping and doctors were wanting to speak with me.  So this is what it feels like to suffocate and almost die from stress. 
Then in the midst of all the chaos, a patient from another room, just happened to be walking down the hallway, and he poked his head in wanting to see what all the excitement was. 
Just about that time…the bathroom door opened.  Everyone…the husband, the techs, myself, the two other nurses, the security guard, the HOA, the environmental services person and of course the other patient all crowded into the bathroom to see what had happened to the patient. 
And there stood the patient, butt-naked, holding her arms in the air, pumping with victory.  She had pulled out her PICC line (of course), and disconnected her catheter from its drainage bag.  The bag was above her head in her left hand, and the catheter was hanging straight down, streaming urine.  There was blood and urine everywhere. 
I am absolutely sure, we were all standing there with our mouths wide open…not exactly believing what we were seeing.  She slowly lowered her arns, and then raised her finger and pointed at me.  “Get her away from me, she is trying to kill me.”  UM…EXCUSE ME…WHAT!!!!
I saw everyone trying not to laugh and failing miserably.
“Please call the police, I would like to report an attempted murder.”  She said, glaring at me. 
Everyone looked at me…I didn’t know whether to laugh, cry or to scream.  “What…um…what…uh…I’m not trying to kill you”, is all I could say. 
“You thought I was asleep…but I tricked you…I was only pretending.  I heard you…You and my husband…I heard you both.  You are plotting to kill me so you can run off together.”
The almost 90 year old man looked at me and whispered, “I’m so sorry”.  I did my best to smile back at him.  I will never live this down.   . 
My preceptee took over, getting her back to bed, dressed, new catheter, new IV, and removed the PCA, while of course I had the privilege of calling the doctor at 0400.  She was really nice…of course after she laughed hard core at me.   OMG…really…and then the teasing started.  “Alicia, you never mentioned that you have a thing for 90 year old men…I didn’t know you had a grandpa complex.”  And so it begins…yet again.

How About Some Dancin?

Every now and then I will have a patient that makes such a difference in my life that I will never forget them (sometimes this is not a good thing, but others its a great thing). 
It was a busy night from the get go.  And then one of my patients decides that he is going to be difficult and go septic.  Since this is not a good thing, and usually requires a lot of extra monitoring, these patients are usually moved off of our floor.  However, this night, the doctors had decided to leave the patient here.  He was stable for the most part.  Sure he had a dobhoff tube, and was very jaundice but he was in great moods. 
The tech and I went in to clean the patient up.  As we were in there we quickly discovered what a character this patient was.  He very quickly joined in with our banter and was picking on us.  He asked me to go dancing and was flirting with the tech.  Next thing, we knew he was romancing both of us by singing us Robert Stewart songs.  He was actually a pretty good singer (or as good as anyone could be with a tube going down the back of their throat).  The night passed quickly with him being a tease and a flirt. 
However, when I came in the next night, I knew that he was not feeling well at all.  He was not his joking self and would barely say a word at all.  I convinced the doctors that he needed to be moved to a higher acuity.  The doctors wanted a CAT scan before they moved him.  The patient was too afraid to go by himself so I asked the tech to go with him.  When he returned to the floor, it was time to transfer him to the other unit.  It was rough because when he realized he was leaving us, he started to cry and didn't want to go. 
Over the next couple of weeks, the tech and I went to visit him on the other floor.  It was super cute because every time, we came to visit he would get this huge grin and start to sing us more songs.  It was great to see him improving.  He finally improved enough to go home, and the night before he left I went to see him for one last visit.  He was in the best mood I had ever seen him in.  He of course sang me a few songs and of course flirted and teased.  He reminded me that I owed him some dancing.  I laughed and said "Well you never know".  He grinned and said that he would never forget me. 
It was great to feel so appreciated.  It was also amazing knowing that I had made such a difference in this patient's life while he was here at the hospital.  Every time I hear a Rob Stewart song now, it makes me think of him and his positive attitude while he was here. 

Nursing Ethics

So this past week has gotten me thinking about nursing school and when we talked about nursing ethics and the role of a nurse.  We were informed that we would see many ethical issues and we would not always agree with the way things were handled in the practice.  To make this easier on us to decide whether something was ethical or if it was our own personal biases and feelings making us feel uneasy, we were taught about the different principles of nursing ethics: autonomy, veracity, justice, non-maleficence, fidelity, paternalism and beneficence to name a few.  
Of course I have faced many issues where I wondered if nursing ethics or medical ethics were being forgotten, but none quit like this one patient I cared for this week.
She was an elderly lady who was in with a bad prognosis.  She was dying of cancer...stage IV.  There was nothing else that could be down and in fact the treatment was only prolonging her misery.  She was alert and oriented during the day, but at night she experienced sun-downers and would quite often forget where she was and have to be re-oriented. 
Her family was great and took turns in a rotating schedule staying by her side at all most all times.  However, they felt that she should not be told the truth of her condition.  They did not want her to know that she was dying and that the treatment was not helping.  They ordered the doctors and nurses to not say a word about the prognosis and in fact to tell her that she was getting better.  The doctors tended to agree saying "she's confused anyway so what difference does it make...she's not aware of what is going on". 
I was very disturbed by the response of the doctors because I knew from first hand expierence that the patient was in fact mentating and did know what was going on around her, thanks to many great conversations. 
One night while I was in the room doing a dressing change, the patient asked me, "I'm dying aren't I?  This is the end, I can feel it."  I looked up at the daughter and had to make a decision quickly about how I was going to answer it.
I'm not usually one to beat around the bush, or not be direct when a patient asks me a question but I knew that I had to tread carefully with this answer.  I looked her in the eye and told her something like "Well honey, you know your body and mind better then anyone else, and many times, the feelings we get are our mind's way of telling us the truth about our health."  She sighed and nodded her head. 
Her daughter walked out of the room, and while I finished the dressing change, we made small talk.  When I left the room, the daughter was waiting for me, with a very unhappy look on her face.  She immediately began to say how it was inappropriate for me to tell her mother that and i had no right. I looked at her and said, "Your mother knows more then you think...she knows that you aren't telling her the truth...she also knows that you guys love her very much and it's hard for you...but what you guys are forgetting is that...by not telling her and not letting her decide to quit the care...you guys have managed to take away the dignity of your mother."  She looked at me and nodded and said she hadn't thought of it like that.  She went and called the rest of her family.  Within an hr, she came back and asked for the doctors to come in and talk to her mother. 
I was happy to see that the patient was finally able to know the complete truth of her situation.  The next morning the patient had decided to go home, and spend the remainder of her days with her family.  She was incredibly happy and at peace with her prognosis and her decision.  It made my day.

Wife From Hell

Sometimes I wonder what in the world I was thinking when i decided that having a job in the public sector was best for me.  I mean I'm not even a major people person.  I am much more content most of the time to be a loner and lost in a good book or watching a movie then being around a group of people.  And after last night I know exactly why that is!
When I arrived on the unit, I was informed that I was getting a new patient.  No one likes to get new admits just because its more work and you don't know the baseline of the patient so if anything starts to go wrong, you may not always know right away.  Anyway, I was getting report and the patient sounded pretty straight forward.  He was being admitted for a pulmonary embolism but was stable. Sounded pretty good.  And then they started to tell me about his wife.
The names that this other nurse called the wife were names that I am not going to repeat but they were pretty vulgar.  And I knew instantly I was not going to have much fun with this patient.
The patient arrived on the floor and before they even made it into the room, the wife was carrying on about how "It must be time for your pain meds....I wonder why they haven't given you any yet...They need to hurry up and do their da*n jobs and get you your meds".  Oh so much fun!!!!
I went into the room and introduced myself.  The patient seemed pleasant and began to assess him.  He denied having any pain at the moment.  Of course with no pain, I was not going to give him his pain meds that were not scheduled but instead only as needed.  I began to ask questions and before the patient could even get his answers out, the wife kept interfering.  "No he does not want that.  I don't know why you think he would.  He does not want an advanced directive, he wants to be a full code...he is not going home...I don't care what you say".  Okay...thanks for the peanut gallery but I'm pretty sure I was talking to the patient.
About an hour after being on the floor he was complaining of pain, so I went ahead and gave him 4mg of dilaudid.  He began to rest.  Within 30 minutes, his wife came storming out of his room.  When I asked her what I could do for her, she demanded. "He needs to be moved right now!!!  I want to speak to your manager."  I was a little confused, and asked her what was going on.  "The patient in the other room, has hepatitis and he's coughing and my husband has been getting radiation and is not supposed to be around that.  And you need to get him moved now!!!"  I told her I would do what I could.  (Little side note...the patient on the other side of the room DID NOT have hepatitis and he was not coughing, he was snoring and sleeping like a baby).
I called and found him a private room but it was going to be 1 in the morning before we could get him moved.  The wife was not happy with that and I swear I really thought about slapping her when she rolled her eyes at me...but I was very pleasant and polite.
Another hour passed and his wife came flying out of the room and demanded I go check on him.  When I entered the patient was sleeping, I listened to his lungs and noticed a little bit of wheezing so I got a breathing treatment ordered.  As I was listening to him, he told me he was hurting, so I got him 2 mg more of dilaudid.
After the breathing treatment the patient went back to sleep, and started to have upper respiratory sounding wheezing and loud snoring.  Now this was because of the pain meds and the relaxation of the throat, but the wife was convinced that I was trying to kill him.  Needless to say 1:00 could not come fast enough for me.
At 0230 I was finally able to move the patient to a different floor, but let me tell you that wife wore me out to the point, I was not sure I was going to survive the last 5 hours of my shift.

Um...You know...It's Not...That Bad??

One thing that more expierenced nurses are constantly telling me is that it will get easier to take care of patients who have received bad news.  However, I find this a little bit sad.  I hope that it doesn't get easier for me...because I don't want to be that calloused or hard. 
This past week I cared for a young man who had been admitted for meningitis signs and symptoms.  He was treated with antibiotics and he started to get better.  Then he began to get worse and none of the doctors could figure out why.   He was just not responding the way he should to the treatment.  So of course, the MDs ordered a ton of blood work and other tests. 
The patient was anxious as he waited for the results.  He said he had an idea of what the result would be, but he was hoping it wasn't going to come back as HIV.  Two days later, the results came back and it was indeed HIV.  The MD went into tell the patient just as I arrived for my shift.  The MD came out of the room to find some tissues and it was clear that it was hard on her too, as she was crying. 
It was a tough night caring for this patient, because 1) what do you say when one hears this news 2) how do you help him accept the results. 
He was very depressed and sad throughout the night, but it was clear that he was definately working through the five stages of grief and by morning, he was well onto his way to acceptance.  He was even telling his family members and friends. 
It was difficult working with him and not knowing what to say, because it's easy for me to say all the right things, but it means nothing since I don't really know what its like. 
Although I may have lots of occasions where patients receive bad news, I hope that it will always bother me a little bit.  I hope that I never become so hard and calloused that I can not feel empathy for my patients. 

Vacation!!!! Or Not!!!

So for the last two weeks I have been on vacation from the hospital.  (Well actually, I'm pretty sure I'm going to just start calling my vacation time, sick leave, since the last two vacations, I have gotten sick).  It has been nice to catch up on sleep and not really HAVE to do anything.  But I was thinking about it and even though I was not in the hospital...I really didn't stop nursing.  Yes, the technical hands on skills part, but overall I guess it's true when they say: "Once a nurse, always a nurse".  Looking back on the two weeks, I see that most of my everyday activities could be defined or seen as part of nursing, especially since nursing isn't only a profession but really more of a way of life. 
On my days off, it was nothing for me to answer medical questions for family members, friends, and yes even those complete strangers who happened to notice I was a nurse.  (It kills me how often I can be out in public on my days off, and people will ask me "Are you a nurse?"  It especially cracks me up when this question comes when people watch me wash my hands and they say "I can always tell just by how you wash your hands".) 
The things I do everything can often be described as "nurse" things: giving advice to a new mother about nutrition, care seats, and baby behavior, letting others go first in line, actively listening to friends or family members, volunteering my time, and of course just thinking like a nurse, whether hanging with friends or making my bed at home (got to love those sheet corners). 
It is amazing to me how for the first time, I really realized that nursing is not just a 12 hour job, or even a job that can be left at work and not taken with us where ever we go.  Nursing isn't only a job at all, but rather a life time commitment of changing people's attitudes and lives, if only in the little everyday things that we do.  So while I may have gotten a break from the hospital, there was no break from nursing. 

He Has a Crush on You!

One of the reasons I like working on an acute care floor, is most of the time, the patients are alert and oriented enough to develop a therapeutic relationship with them.  I enjoy being able to carry on conversations with the patients and family.  Usually if a patient is giving everyone else a difficult time, I can usually use my charm and charisma to make them like me.  However, sometimes this is not a good thing. 
I had this middle aged man who had an epidural abscess.  This abscess led to paralysis from the waist down. 
The patient was pretty upset about this, because it meant more time spent in the hospital and not only that but the MDs weren't aware if he would fully regain control of his legs.  So of course he was a little depressed. 
I always try to get my patients interested in conversation to help keep their minds off their prognosis if only for a few minutes. This patient had been with us for about a month, when my co-workers began to tell me that he had a crush on me.  I just laughed and brushed it off. 
But then I began to realize that my co-workers were right.  The light hearted joking and conversations with the patient had changed, to talking about my personal life...if i had a boyfriend, if I wanted kids, and other personal information.  Then one night it crossed the line. 
We were talking about everyday things when he asked "Do you like kids?"  I told him of course I did.  He then proceeded to tell me that I could have his, but of course it was a two for one package and he came with them.  I just laughed it off, but could no longer ignore the fact that he did in fact have a crush on me.  It made it a little awkward whenever I had to go into his room...but I just went about my job.  And of course it gave my co-workers even more ammo to tease me with.  :)

Code!!!!

I swear this was the worst week of my life.  Not only were the shifts really busy, and then the glucose patient situation, not to mention the perforated bowel patient last night, but this morning, another situation happened.  We were in the middle of giving report, and the techs went running down the hall yelling for a nurse.  It wasn't my patient, but the other nurses were farther away.  I jumped out of my seat (and apparently over another chair, which the other nurses love to mock me for...my athletic abilities) and ran to the room.  Another nurse was right behind me.  Neither one of us knew anything about the patient.  As we arrived in the room, we noticed the patient was a gray pallor and unresponsive.  We tried the sternal rub with no response...we checked his vitals and glucose levels and everything was normal.  He had a pulse so we called an assistance please.
He had pulled out his IV and so we quickly attempted to get one in before all the MDs, Rapid Response, and everyone else arrived.  Within two minutes, the room was packed with people, and since it wasn't my patient, I stayed in the hallway running for supplies and pretty much doing anything that needed to be done, but staying out of the way at the same time.  They ended up intubating the patient at the bedside on the floor and moving the patient to the ICU.  What a nerve wrecking ending to a work week.  

Perforated Bowel

So I survived the glucose patient last night, only to have another situation the next evening when I arrived.  Once again in the middle of report, the techs yelled for a nurse.  As I ran into the room, I saw the patient laying flat on his back vomiting.  I quickly helped the techs, turn him onto his side, and raised the head of the bed.  When I went to grab the suction, I discovered there was no suction set up.  I quickly had a tech run to get the necessary supplies.  As I was waiting, I noticed the smell of the vomit.  It was stool smelling.  That was not good at all.
  The MD and Rapid Response quickly reappeared (apparently they had just left the patients room, and found him to be stable).   They quickly changed their diagnosis to a perforated bowel in need of emergent surgery.  He quickly left for the OR and the shift returned to it's normal pace.

Where is the Nurse???!!!!

So being the kind person I am, I volunteered to come in early for a fellow nurse who had a family emergency (I don't know what I was thinking, since that put me on a 16 hr shift, but hey you know it could be a little fun).  I got report and settled in to start my shift.  As I was looking over orders, the tech comes running in and tells me that one of the other nurse's patients has a glucose of 10 and she can't wake him up!
Of course, we couldn't find the nurse so I went running into the room.
I tried to wake him up and got no response.  I attempted the sternal rub, nothing.  I ran back to the nurses' station to grab some dextrose.  When I got back into the room, the first thing I noticed was that the patient did not have an IV...well dang it...there goes the dextrose idea.  I quickly ran back and grabbed some glucagon and called the Dr. and rapid response.
I ran back to the room and gave the patient the glucagon.  By this time, the MD and rapid response arrived. They asked a million questions, and I felt very stupid when all I could say was "I have no idea, he's not my patient, I don't know where the other nurse is". They pretty much took over and left me to run to get more glucagon, IV fluids and line, call report to the other floor and stay in contact with the MDs.
They quickly got the patient responsive and back to his baseline.  As they were wheeling him off the unit, the Rapid response nurse came running back and told me to call the MD because the patient was having a heart attack.  I called the doctor and put in the new orders.  About this time, the other nurse reappeared and wanted to know what was going on. She informed me that the patient was supposed to be discharged within the hour.
Since the patient was gone, I went about my very long shift, and just barely survived.

Nursing and Stereotypes

One of the most important things that nurses need to do is to keep their stereotypes and prejudices at the door, and out of the profression.
This is one of the hardest things to do.  I've never considered myself overly judgmental, however, I have learned that my sub-conscious many times, jumps to conclusions on it's own, whether I admit it or not.  And unfortunately, its those moments that show me just how bias I really am.
The ER called to give me report.  The patient's admitting diagnosis was endocarditis (usually this is found in street drug users, especially if their drug of choice is percocet due to the fungal coating).
Stereotype number 1) "So he is an IV drug user?"  She told me, that of course he had denied it,but they were waiting for the result of the urine test.
When the patient arrived on the floor, and I saw him, my first impression became stereotype number 2.  He was this big muscular man with multiple tattoos and piercings, and he wore leather like he rode a motorcycle...in fact there was a helmet on the bed with him.  "Of course this man uses drug...there is no way he doesn't", I quickly caught my mind thinking.
As we were going over his admit paperwork, he adamantly denied using street drugs, smoking and alcohol.  I didn't think that I let anything show on my face, but I guess that my tone of voice gave something away.  As I was walking out the door, he quietly said, "I am a doctor.  I have been in Africa for the last three years, and I picked up the fungal infection there".
Ummm...I'm totally kicking myself now...This had to have been my most regretful and embarrassing moments so far.
I turned back around and quickly apologized...and found it really hard to look him in the eye.  He laughed "I'm used to it...you have no idea how many times I get that very reaction."  The rest of the night went smoothly and we were able to put it in the past thankfully.  He was very interesting and had some great stories to tell.
He was also the patient that made me re-examine the way that I view patients just based on report or things that I have heard other nurses say.  I made a quiet decision there, to make a harder effort to not judge my patients.  
  

Oh...There's That Vein

I love it when I have patients that make me smile and laugh.  They make the night go by so much faster.  One patient in particular had me about in fits and it wasn't even my patient.
The nurse I was working with asked me to go in and see if I could get some blood cultures on the patient.  Now many times when getting blood cultures we have to stick the patient twice...once on each arm.  The patient was upset and was complaining and trying to refuse.  Normally I let the patients refuse, however this patient was running a very high temp and the blood cultures were important.
I asked the tech to come in and help and asked her to distract the patient.  As the tech was talking to her, I tied the tourniquet and started to look for a good vein to get blood from. There was nothing.  I could not find a vein for the life of me.  Then the tech started to ask the patient about the men in her life.
The patient started to tell us about a man named Willard and another one named Ted.  She went on and on and was blushing as she was talking.  It wasn't very hard to figure out that she had a crush on these two guys (granted she was confused, but she was crushing on these two).  As she kept talking, her veins magically began to appear.  Not only did they appear but they popped out nice and big.  I was able to quickly get both of the sticks in and get the blood I needed.  She was so preoccupied with her guys that she was not even aware of when I stuck her.  It was a little amusing and made for a good laugh. 

Funny Moment

It’s important to remember to take time to laugh in the nursing profession.  Many nights, my co-workers are extremely busy and stressed out regarding the patients and yet we always try to find something to laugh about (and that’s why I’m a God send to my peers…because I’m good at making people laugh). 

For this story I can’t really give you much background information because it would totally ruin the story.

One morning as we were doing our bedside rounding and checking in on the patients…I managed to get a really good laugh at my co-workers expense.  The last patient we went in to check on was sitting up in bed drinking some apple juice.  Now normally this would not be out of the ordinary, but all of a sudden my co-worker began to freak out a little.  She jumped to the side of the bed and quickly took the apple juice from the patient.  I started to laugh and try to hide the laughter all at the same time.  The nurse was holding a urinal filled with apple juice!!!  This patient had been refusing to drink out of anything but the urinal all night (of course I made sure it was a clean one before I let him continue to drink from it).  The nurse coming on did not know this and thought he was drinking his urine.  The patient was not happy about his juice being taken away…and when I explained the situation, the nurse gave him back his juice.  I have to say it was one of the funniest things I had seen in a while. 

Frustrating Part of Being a Nurse

I’m going to admit to something that really is not a good thing at all.  There are times when my patients get me so frustrated I just stop caring and really don’t want to help them at all anymore.  I get into this mode where if they don’t care if they get better then why should I and what difference does it make if I go out of my way.  Like I said not a good thing at all…and I’m working on it…but hey I never said I was perfect ;)  I have two patients in general this last month that has gotten me feeling this way.

One is a patient with Cystic fibrosis.  This diagnosis means that she is in fact a frequent flyer and in the hospital every few months or so.  That in itself is sad because it’s not an easy disease to live with.  Anyway…this patient is very familiar with the healthcare system and because of this they have become a drug seeker.  This patient knows the words to say and the manipulations to get what they think they need.  It is very exhausting…mentally…to care for this patient…because you have to constantly be on your toes and be one step ahead of them so that they don’t manipulate you into giving them what you want. 

Anywho…this patient is also a smoker…not a very good combination with the chronic lung disease they have…but hey what do I know…I’m only a nurse…The patient consistently asks to leave the floor to go down for a smoke.  No normally we can’t really push the situation that far and refuse to let patients leave…but because of the patient’s past history of going down and shooting up Benadryl in the PICC line…we do have cause to tell this patient no…Usually the nurses just do not want to deal with it and so they let the patient go…but when a nurse does say no…boy does the patient ever get upset…even to the point of unhooking the IV fluids by themselves and going down anyway…and of course coming back high and strung out.  This patient is in fact only doing herself a great injustice and speeding up the progress of the diagnosis…but they can not be argued with.  It is frustrating on so many levels.

Patient number 2 has endocarditis from using IV drugs.  The drug of choice is Percocet which of course has that layer of fungi on it which does not mix so well with the heart.  The endocarditis required heavy duty IV antibiotics and because of the past history of drug abuse the patient had to stay in the hospital for 2-3 months to finish the antibiotic therapy.  At first the patient was talking big dreams of staying clean and “I gave up that lifestyle…I won’t ever do drugs again, I came too close to death this time.”  (Now this patient had had a mitral valve replacement 6 months earlier and had already ruined it with this new trip to the hospital).  The patient seemed sincere and many of the nurses choose to believe what was said…that was until we started to notice that the patient was high and strung out for a good three or four day stretch.  A family member had come to visit him and our conclusion was had brought a little extra to add to the party.  The doctors were a little mad and did a urine drug test (of course we didn’t tell him what it was for…instead making some excuse about the antibiotics and how it’s routine).  The drug test came back positive for a drug that we were not giving him.  The patient was required to sign a drug- free contract…basically saying that if it happened again the doctors would be forced to discharge the patient even though the antibiotic treatment would not be finished. 

Everything was good for about a week…I happened to be off and when I came back I heard that the patient was doing very well with no back slides to the drugs.  However, that first night back, I became very suspicious of the patient’s behaviors.  One of buddies of the patient ended up being in the hospital around the same time and so they began to spend a lot of time together.  Now this other patient was on a PCA pump where he was getting 0.2mg dilaudid.  I began to suspect the reason they were spending so much time together was to share the dilaudid.  Turns out the patients were unhooking the PCA and then hooking it back into the IV access of the other and in fact sharing the pain meds.  When I found this out…let me tell you that I was very upset.  At that moment, I wanted nothing to do with either patient…and didn’t really care anymore…but I had to put that behind me and care for them both.

The caring of healthcare professionals are not enough.  The patient has to want to get better and improve, or there is no chance anything will ever change.  All the nurses and doctors can do is try to help the patients see what is best and what they should do…but many times while we are saying and teaching it…we know that it will not change and they will just be back in the hospital a few months later for the same self-destructive habits.  It has to be one of the most depressing things about the job…knowing that you can’t help everyone. 

Hardest Thing

This week I’ve had a patient who may be the first patient that I actually have cried over a patient and his situation.  I’ve had this patient for a couple of weeks.  He has a terminal form of cancer and has a bad prognosis.  In the last couple of weeks, I’ve helped the patient work through his diagnosis, progress through the stages of grief and became a reassuring listening ear.  Nursing school prepared me for all of these things…however nursing school did not prepare me for what I was/am feeling about the situation.  I wasn’t prepared that I would also experience the stages of grief…not as prominently as the patient and family but it is still there.

In the beginning I believed there was something that could be done to help this man.  I wasn’t sure what but I was sure that the doctors would be able to do something…after all modern medicine has a lot of miracles.

After the denial I began to become upset at the situation.  The patient was in the hospital, and had been for many weeks.  He had only seen his wife twice since then and his kids not at all.  His wife seemed to not want to deal with the problem and because of this she kept the kids away from the hospital and their father.  At first I was upset and couldn’t understand and then realized that this may be the wife’s way of dealing with the grief. 

I’m not sure I ever entered the bargaining stage, but I was able to witness my patient endure that stage.  He bargained with God for many days, before he moved on to the harder to handle “What if…” moments.  “What if…I had done this differently?  What if…I had been a better father/husband?  What if I had spent more time with the family”?  This was a tough stage for the patient because the more “what ifs…”  the more and more depressed he got.  It is hard to see your patient become depressed to the point of giving up and not seeing the point anymore…especially in this particular situation…because the hope of life isn’t there anymore.  It’s hard to know that there isn’t much you can say or do at this point to help.  It’s especially hard to know the patient is facing the hardest moment of his life…with no support and no one to be there with him. 

The patient finally agreed to sign a DNR and consider the option of hospice and the return home.  With this option he began to become less and less depressed.  He had something to look forward to…returning home to spend his last days with his family. 

As a nurse, I wanted to help him and make him less depressed but at the same time…I know that there’s not much that can be said or done.   Although I know this…it does not make it easier to face the feelings that are forced upon you…I don’t think there is any way to prepare yourself for that.  

Scardey Cat

The other day at work, a co-worker told me that she didn’t believe I ever got mad…since in a year’s time she has never seen me mad or angry.  I quickly disagreed with her and told her that I do get mad, and in fact she had just missed the opportunity to see me very upset…in fact I was upset enough to want to physically harm someone (this time I not only wanted to but was very tempted to just reach out and punch some common sense in the guy).

I had switched to day shift for a few days to help out with the shortage our unit is experiencing.  Because of this switch I had to interact with a lot more people: family members, doctors, social workers, teachers, guards and patients.  One of my patients was a prisoner and did have a guard at the bedtime.  As I received report on the patient, I quickly learned that the patient’s ammonia levels were critically high.  This caused the patient to go crazy and act irrational and crazy.  The night before he had laid on the floor and crawled on it like a dog, got on the footboard of the bed and stood on it and tried to fly off of it…of course leading to him falling flat on his butt.  The patient was quickly restrained and given some Ativan to help calm him down. 

When I arrived he was sleeping due to the medication and had one hand and foot cuffed to the bed.  When I entered the room to draw some labs, the guards were changing shifts.  This meant that I got to listen to the conversation.  The night guard told me to be careful and to keep my eyes peeled.  I agreed and assured him I would.  The new guard coming on decided to get a smart mouth right from the beginning and stated: “I want to use my gun today…maybe I’ll get to use my gun on him…because I guarantee I will not hesitate to shot”.  This statement in itself upset me and did not start the day off right between this guard and myself. 

As I was finishing up the lab draws, the new guard was asking me a million and one questions about the care of the patient.  I kept telling him that I was not able to tell him anything.  He insisted that he needed to know so he could tell the facility.  I told him to have the facility call me and I would talk to them about the patient and only them…he then mumbled that he was not a guard at this particular facility but was only assigned to the patient because his location was closer to the hospital then the facilities guards.  This did not make me any happier with the guard.

The rest of the morning the patient slept off the medications and was fine.  About 1400 the patient began to awaken.  He was very sweet and apologized for what had happened the night before.  He was very compliant and followed all of my prompting.  However as I was walking out of the room, the guard asked me, “would you knock him back out…he’s getting mouthy”.  I looked at the patient who of course overheard the guard.  He quickly reassured me he was not getting mouthy.  I nodded at him and walked out of the room. 

The guard continued to be mean to the patient for the rest of the day.  The patient was beginning to get upset and edgy but remained calm and polite.  The patient and I could not wait for guard shift…it could not come fast enough for us. 

Seriously, the guard is there to protect if anything happens with the patient…however, I found myself more afraid of the guard, because I could totally see him pulling his gun and shooting one of the health care members in his ambition to shoot the patient.  It was just setting up to be a bad situation if something did happen.  Fortunately nothing occurred and the guards finally switched out…but if I ever have another patient with that particular guard…I will remember the type of man he is…a sacredy cat who is probably more dangerous with the gun then the patient would be.