So here's the scenerio:
I get a patient at 1900, the report was right sided weakness and slurred speech from 1100-1500. Symptoms have since resolved. BP is 114/60. I rush him to CT and neurology says its most likely a TIA, will admit to the stroke unit for observation. We get back to the ER, the patient also mentions he has had a cough for a couple days. Chest x-ray is ordered, hes got a touch of pneumonia.
2100: BP is 112/59 and IV antibiotics are going in at 250 ml/hr.
2200: Admit orders come through with the second antibiotic ordered at 250 ml/hr and maintence fluids at 40 ml/hr.
2230: BP 102/55. I think "Ahh poop I still need to hang fluids. Well we're super short on pump channels and he's getting much more than that from the antibiotics, I'll come back to it." Pt is still AAOx3, no neurological deficits.
2300: Code comes in. Being a team player, and loving a good code, I jump in to help.
0000: I'm supposed to be leaving now, but the code just came in and I have to clean up my patients. Neurology calls me.
Neuro: "I've been trying to call you for an hour!?!"
Me: "I'm sorry, a code just came in. Whats going on?"
Neuro: "Why is the patients blood pressure so low?? Why haven't his fluids been hung?! This is unacceptable! He could have had a stroke! Bolus him with 250, hang the fluids, get a new bp and call me back when the bolus is done!!"
So first I start to freak out. Did I do something way wrong? I'm still pretty new to this nursey thing, and I'm super anxious about making sure I don't do anything to cause harm to my patients.
But then I start thinking and getting angry. His blood pressure dropped 10 points since arrival, which is completely normal. Neurology saw this patient twice, and internal medicine evaluated him. No one was concerned about his blood pressure. His fluids were ordered at 40/hr, so because of me he didn't get 120 mL's from when the order was placed until neurology called. He did, however, get 750 mLs from the IV antibiotics.
At this point I'm getting angry, because of the way he was talking to me and for what he was accusing me of. (Plus, my shift was over, and I felt like I needed to clean this up before leaving.)
When I get angry I shut down. My face turns bright biohazard red. My eyes well up. My hands shake. My voice cracks. I'm not sad or upset, I'm angry, but people can't tell the difference and it's so frustrating. I don't want to cry. I'm not upset because someone yelled at me. I'm ANGRY.
So I'm trying to fix this (and leave for the night) and people keep coming up to me "Whats wrong?? Are you okay??" Yes. I am. Leave me alone. NOW.
I infuse the bolus in 15 mins and hang the fluids. Recheck the pressure and (shockingly) it's the same. I call neurology. "Well how long ago did the bolus end??" Uh. Just now. I did exactly what you asked me to do. He makes no changes to the orders but insists that I travel with the patient to the half hour MRI he just ordered because "the blood pressure is unstable." NO ITS NOT! It dropped 10 points since arrival! This guy is fine! And then he said "Once the MRI comes back, if it's negative, I don't really care about the blood pressure."
I'm fuming, and I cant find anyone to give report to.
Finally, one of the murses who is precepting said he would take it. I can barely get through report because I'm shaking and trying not to cry.
I clocked out at 0130, got in my car and finally the tears started flowing. Not sad tears, angry tears.
You may read this and think I was completely wrong, and maybe I was. But if the doctors felt it important for him to get fluids, I would expect an order > 40 mL/hr. If it was at 150, I probably would have searched for the part I needed and hung them. I was angry that they all knew what his blood pressure was on arrival, they had been down to check on him, and that this 10 mmHg change was enough for them to yell at me. I work hard and I do the best for my patients. The condesention in his call threw me into third gear. I can't work when I get like that. My mind gets all foggy, I don't talk to my coworkers, and everyone knows something is wrong. I hate that I have such a dead giveaway.
The patient ended up being fine, I got home around 0215, to wake up at 1000 and do it all again the next day.
TL;DR: I look like a lil bitch when I get pissed.
-K
Tuesday, March 31, 2015
Wednesday, March 18, 2015
Brief hiatus
Hay yall! I am currently in the middle of a two week vacation. It is wonderful. I am spending my time doing absolutely nothing. I apologize for my lack of posts but to truly take advantage of this time off, I am thinking about work as little as possible. Do not fret, I shall return!
-K
Saturday, March 7, 2015
An open letter to floor nurses
Dear floor nurses,
You hate us. We know you hate us. My goal here is to see things from your side, and tell you how it is on our side. Everyone has those stories "One time the ER sent me up this patient and it was a TRAIN WRECK." I ask you to put aside that, and read with an open mind. I accept that floorbies and ERs will never walk hand in hand to get coffee together, but if one person reads this and isn't as sassy in their next patient handoff, I'll consider myself a success.
This complaint irks my soul. I'm sorry kids, but it does. I know it sucks to get a patient at change of shift. But if you're getting a patient from me then I'm getting a brand new one as well. Believe me, I'd much rather hang on to this admission that I finally have settled in bed then ship them off for a new one. Just as its unacceptable to tell your night shift "I got this patient at 1830 so I didn't do the admission stuff", I cant tell my relief that I didn't complete any orders on my brand new one either. And it is completely untrue that we hang on to the patient for the day, and send them up at the last minute. As soon as the bed shows up as ready, the secretary is calling transport and the patient is going to their bed. The timing sucks. And we really can't help it.
Plus, imagine it from the patient's point of view. They've sat in an uncomfortable stretcher for hours, waiting for CT results and admitting MD evals, while watching a psych patient running down the hallway. They come to the desk every hour asking when their bed is going to be ready. They are miserable, and the family members are about ready to walk upstairs and clean the rooms themselves. Please, don't bring any irritation onto them when they get wheeled into their room at 1845, because they've probably been waiting ALL day for this.
Y'all have to understand that our job, and our mentality is to stablize the patient, then get therm where they're going. We fix things pertinent to the issue at hand, then send them away. If the ER nurse isn't giving antihypertensive medications and the blood pressure is out of control, that unacceptable. If the PCA or the heparin gtt or the blood transfusion was ordered hours ago but never given? Unacceptable. But the NSS 80mL/hr, the subq lovenox and the colace? It's not our priority. Personally, I try to at least draw any due labs I can before my patient goes upstairs because I can draw from the line and the floor nurses at my hospital can't. Half the time the pharmacy takes hours to send us the medications. Flowtrons? Forget it. Good luck trying to find a pair. But if an ER nurse is feeding the patient and not covering with their sliding scale insulin, or giving their needed blood pressure medications that's unacceptable.
Our report/patient hand off is very different from yours. Mostly "Mr Johnson is here for L sided CP on and off today. We gave him 2 sublingual nitro and that decreased his pain. He has an IV, I sent labs. HR has been SR 80s, blood pressure has been on the high side, 150s systolic, but the docs are just watching it for now. He'll probably be a tele-admit." We don't do a systems run through or delve into the past medical hx unless, like mentioned before, its pertinent to the issue at hand. I know it's frustrating to get half the story, but it's just not our priority. We operate to focus on the problem in front of us, not to plan care for their entire hospital stay. It's two totally different approaches to patient care.
That being said, it's inappropriate for the nurse not to know what hip is fractured, what the vent settings are, what heart rhythm the patient is in, etc. That is bad nursing practice, and should not reflect the department as a whole.
Eh, yeah, guilty. We aren't required to give report to med-surg or tele floors in my hospital, just ICU and stepdown units. So when I give a courtesy call to the floor and they won't come to the phone I get irked. And I shouldn't. I am sorry for rolling my eyes over the phone. You guys are just as busy as us, and I understand that. However. If you do take my call, please don't use this as the opportunity to get out of taking the patient. The patient has already been accepted and approved by the doctors and the nursing supervisor, take it up with them and not me please?
TL;DR: Floors and ERs are both as busy, just totally different. Respect each other.
-K
You hate us. We know you hate us. My goal here is to see things from your side, and tell you how it is on our side. Everyone has those stories "One time the ER sent me up this patient and it was a TRAIN WRECK." I ask you to put aside that, and read with an open mind. I accept that floorbies and ERs will never walk hand in hand to get coffee together, but if one person reads this and isn't as sassy in their next patient handoff, I'll consider myself a success.
We give you patients at change of shift.
This complaint irks my soul. I'm sorry kids, but it does. I know it sucks to get a patient at change of shift. But if you're getting a patient from me then I'm getting a brand new one as well. Believe me, I'd much rather hang on to this admission that I finally have settled in bed then ship them off for a new one. Just as its unacceptable to tell your night shift "I got this patient at 1830 so I didn't do the admission stuff", I cant tell my relief that I didn't complete any orders on my brand new one either. And it is completely untrue that we hang on to the patient for the day, and send them up at the last minute. As soon as the bed shows up as ready, the secretary is calling transport and the patient is going to their bed. The timing sucks. And we really can't help it.
Plus, imagine it from the patient's point of view. They've sat in an uncomfortable stretcher for hours, waiting for CT results and admitting MD evals, while watching a psych patient running down the hallway. They come to the desk every hour asking when their bed is going to be ready. They are miserable, and the family members are about ready to walk upstairs and clean the rooms themselves. Please, don't bring any irritation onto them when they get wheeled into their room at 1845, because they've probably been waiting ALL day for this.
We put IVs in the AC
So when a patient comes in, sometimes they're really sick, sometimes they're putting on a really good show. You could be getting a nice, stable patient that looked completely different when they walked in. Either way, we have to get an IV in, fast, and a nice big one is optimal. Certain medications require that placement. CT scan prefers 18G or larger above the wrist for any imaging with contrast, so if they have any type of trauma or we think they're getting imaging, that's the spot. Sometimes they're so dehydrated on arrival, that's all that's popping up. Sometimes they REFUSE to let us go in the hand. It's annoying to us too..."Mrs. Jones, remember leave your arm flat so the fluids can drip in!" If I have time to search around for a different spot, and if the patient doesn't require a large bore IV, I try my best to go somewhere else, otherwise I'm going to be happy with what I've got.
We don't start admission orders.
Y'all have to understand that our job, and our mentality is to stablize the patient, then get therm where they're going. We fix things pertinent to the issue at hand, then send them away. If the ER nurse isn't giving antihypertensive medications and the blood pressure is out of control, that unacceptable. If the PCA or the heparin gtt or the blood transfusion was ordered hours ago but never given? Unacceptable. But the NSS 80mL/hr, the subq lovenox and the colace? It's not our priority. Personally, I try to at least draw any due labs I can before my patient goes upstairs because I can draw from the line and the floor nurses at my hospital can't. Half the time the pharmacy takes hours to send us the medications. Flowtrons? Forget it. Good luck trying to find a pair. But if an ER nurse is feeding the patient and not covering with their sliding scale insulin, or giving their needed blood pressure medications that's unacceptable.
We give incomplete reports
Our report/patient hand off is very different from yours. Mostly "Mr Johnson is here for L sided CP on and off today. We gave him 2 sublingual nitro and that decreased his pain. He has an IV, I sent labs. HR has been SR 80s, blood pressure has been on the high side, 150s systolic, but the docs are just watching it for now. He'll probably be a tele-admit." We don't do a systems run through or delve into the past medical hx unless, like mentioned before, its pertinent to the issue at hand. I know it's frustrating to get half the story, but it's just not our priority. We operate to focus on the problem in front of us, not to plan care for their entire hospital stay. It's two totally different approaches to patient care.
That being said, it's inappropriate for the nurse not to know what hip is fractured, what the vent settings are, what heart rhythm the patient is in, etc. That is bad nursing practice, and should not reflect the department as a whole.
We get irritated when the floor won't take our call
Eh, yeah, guilty. We aren't required to give report to med-surg or tele floors in my hospital, just ICU and stepdown units. So when I give a courtesy call to the floor and they won't come to the phone I get irked. And I shouldn't. I am sorry for rolling my eyes over the phone. You guys are just as busy as us, and I understand that. However. If you do take my call, please don't use this as the opportunity to get out of taking the patient. The patient has already been accepted and approved by the doctors and the nursing supervisor, take it up with them and not me please?
We don't pay attention to skin care
Eh, yeah, not as much as I should, I'll admit to that. Anyone coming from a nursing home or incontinent at baseline I turn them, get a look at their back/sacrum and document. In my department, we don't carry all the fancy wound care dressings that the floors have, so its usually just an abd pad and some tape. The floors also take pictures of the wounds, so I'm hesitant to do a baller dressing that's taped down like cement when it's just going to get ripped off during the admission assessment. I will say that I'm really bad at remembering to take off their socks to check for pressure ulcers on their heels. Sorry yall, I'll do better I promise!
In conclusion, I realize there are some things I need to work on from my end. I hope this didn't come off as pompous, I just wanted to give things from my perspective. I give you floorbies a TON of credit, I could never do your job. Everyone fits a different specialty, and we each have a different job to do. And like I said before, if one floor-ER interaction is a bit less sassy after reading this, I'll be a happy nursey.
-K
Wednesday, March 4, 2015
Roles in a Code
When a patient is coding, everyone works as fast as they can to save the life of the patient on the stretcher. While doing clinical rotations in nursing school, watching the ER nurses work together during a code is what enticed and enthralled and sucked me into this specialty. So, here's a list of the roles/responsibilities (in my opinion, of course) that seem like just the right amount of people to be in the room during a code situation. (When it's my patient, I like to do the things marked with a *)
As the ambulance crew is rolling the patient into the room:
RN*: Write down the story from the medics, any medications they gave, what size ETT they used, etc., along with any known patient history and medications. WRITE IT DOWN, you will forget it otherwise.
Tech 1-2: Place the patient on the monitor. Obtain an EKG and a blood sugar. Grab another tech or two if CPR is in progress.
RN 1-2: Get an IV. Two if possible. Tape them suckers down, and draw labs, a whole rainbow, blood cultures, lactic acid, ammonia.
So the patient is now on your stretcher, connected to your monitor/code cart. Docs are doing their thing. And the patient is pulseless.
Techs: CPR, hard, fast and deep. Having two or three techs in the room helps so at pule checks they can trade out.
RN1: Give the medications and guard that IV. If someone accidentally rips the line out, everyone is screwed. When giving a medication, make sure to clearly communicate what you're doing. Saying "1 mg epi is in" loud enough for everyone to hear is key.
RN2: Draw up the medications, and work the code cart monitor. Get those epi bristojets ready. Spike a fluid bag. Be prepared with extra flushes to hand to the med-giving RN. Know how to set the monitor to the correct amount of joules to shock the patient. And MAKE SURE everyone is clear of the patient before hitting the shock button.
RN3*: Watch the clock, take notes, and be the communicator for the team. Make sure everyone is aware of what medications have been given. Know the ACLS algorithm and when it's time for a pulse check or another round of epinephrine. Position yourself by the door, so you can watch the entire team working, and so you can call out for supplies if something is needed.
It's so helpful in situations like this if you can have another nurse or tech standing right outside the door, so if your code cart runs out of epi, or if you forgot to grab an OG tube, they can grab it without taking people away from the room.
It's also important to have a nurse watching the rest of the pod while this is going down. If you look around and realize that you don't need to be in the room, GET OUT. You are probably in the way, and can be so much more useful going out to the desk and seeing what you can do to help everyone else out. The department doesn't come to a halt just because a sick patient comes in. Everyone else still needs IVs started, pain medications and those delicious chicken sandwiches.
*Disclaimer* I'm not trying to say this is the ONLY BEST way to run a code, just how I've observed to make things run as smoothly as possible.
TL;DR: Know what needs to be done while a patient is coding, & if you're not doing anything productive.. GET OUT!
-K
As the ambulance crew is rolling the patient into the room:
RN*: Write down the story from the medics, any medications they gave, what size ETT they used, etc., along with any known patient history and medications. WRITE IT DOWN, you will forget it otherwise.
Tech 1-2: Place the patient on the monitor. Obtain an EKG and a blood sugar. Grab another tech or two if CPR is in progress.
RN 1-2: Get an IV. Two if possible. Tape them suckers down, and draw labs, a whole rainbow, blood cultures, lactic acid, ammonia.
So the patient is now on your stretcher, connected to your monitor/code cart. Docs are doing their thing. And the patient is pulseless.
Techs: CPR, hard, fast and deep. Having two or three techs in the room helps so at pule checks they can trade out.
RN1: Give the medications and guard that IV. If someone accidentally rips the line out, everyone is screwed. When giving a medication, make sure to clearly communicate what you're doing. Saying "1 mg epi is in" loud enough for everyone to hear is key.RN2: Draw up the medications, and work the code cart monitor. Get those epi bristojets ready. Spike a fluid bag. Be prepared with extra flushes to hand to the med-giving RN. Know how to set the monitor to the correct amount of joules to shock the patient. And MAKE SURE everyone is clear of the patient before hitting the shock button.
RN3*: Watch the clock, take notes, and be the communicator for the team. Make sure everyone is aware of what medications have been given. Know the ACLS algorithm and when it's time for a pulse check or another round of epinephrine. Position yourself by the door, so you can watch the entire team working, and so you can call out for supplies if something is needed.
It's so helpful in situations like this if you can have another nurse or tech standing right outside the door, so if your code cart runs out of epi, or if you forgot to grab an OG tube, they can grab it without taking people away from the room.
It's also important to have a nurse watching the rest of the pod while this is going down. If you look around and realize that you don't need to be in the room, GET OUT. You are probably in the way, and can be so much more useful going out to the desk and seeing what you can do to help everyone else out. The department doesn't come to a halt just because a sick patient comes in. Everyone else still needs IVs started, pain medications and those delicious chicken sandwiches.
*Disclaimer* I'm not trying to say this is the ONLY BEST way to run a code, just how I've observed to make things run as smoothly as possible.
TL;DR: Know what needs to be done while a patient is coding, & if you're not doing anything productive.. GET OUT!
-K
Urgent vs Panic
Working in a critical care setting, I've learned very quickly that things can go bad, fast. One minute you're joking with your coworkers and drinking your coffee, the next minute an ambulance is rushing in and you're doing CPR. Some nurses are FANTASTIC to have on your critical care team. The ones who never seem to get their feathers ruffled, who are always anticipating what's going to happen with the patient and always seem to be a half of a step ahead of the residents. It's awesome working a code with nurses like this, everything seems to happen quickly, yet systematically. Then there's nurses that PANIC. When they have a sick patient, it's like the world is ending. They scream and seem to be running around in circles, without actually accomplishing anything. They get super excitable and it rubs off on the whole team, as well as the patient. They aren't thinking rationally. This is where mistakes happen. When you're in this panicked state of mind, it's so easy to trip over the code cart wires, stick yourself with a needle, or have a medication error.
The other day we had a transit bus pull into the ER circle because a rider had collapsed on the bus. The tech and the nurse that ran out to the bus were of the 'instant hysteria' category. I attempted to bring them a stretcher, and about 10 security guards were all running around circles screaming for help.
I went back inside to clear out a room for this coding patient and I can hear them coming screeching and stampeding down the hallway. They try to rush their patient into the room, while a tech is doing CPR on the stretcher, before we had even moved the stable patient into the hallway. Talk about traumatic.
It was one of the more chaotic codes I've been involved in. If they hadn't been so hysterical, it could have completely changed the atmosphere, and they way the entire situation was run. Yes, it was an insane sequence of events, but keeping your wits about you is so important when you work in an emergency setting.
So I beg of you all, know yourself, know when you're starting to feel overwhelmed, and ask for help. DON'T SCREAM. Don't run around with a chicken without a head. Know what needs to be done and do it so mistakes don't happen.
TL;DR: Work urgent, not panicked.
-K
Sunday, March 1, 2015
Patience with Patients
I'm finding it a little difficulty to blog without making my post sound like a nursing note, but here we go
I had this 45 year old woman with cervical cancer, currently receiving chemotherapy, chief complaint of altered mental status. She was a hot mess. She wouldn't sit still, was writhing around in her stretcher, non verbal and not following commands. I could tell she was uncomfortable, and was understanding what I was saying, but was just in so much pain she couldn't listen. My patience was waning as i struggled to complete the simplest of tasks to figure what was going on with her. I had a tech hold her down while I accessed her port to draw labs. I hung fluids but she kept getting tangled up in the line. I couldn't get an accurate blood pressure because she wouldn't leave her arms still long enough for the cuff to inflate. She needed CT scans but there was no way she could lay still enough for her to do the imaging. She kept getting out of bed, and 3 family members and I had a struggle to coax her back in. I cringed every time they came to the desk, because I knew it was going to be another ordeal.
I had already had a really shitty and busy day. I had her, two new patients that I had just thrown IVs in, and one ICU step-down patient that was finally getting settled. Welcome to the ER. I needed coffee. Badly. I was the floor for 8 minutes, tops.
When I get back to the desk, her family member is waiting for me, "We tried to grab you! Her colostomy bag exploded!" I rush into the room and she is now kneeling on the stretcher, elbows on the bed and refusing to budge. Theres stool covering her and the bed, and all she is doing is rocking back and forth on her knees and elbows. At this point I'm about to cry. I can feel my self getting testy while I'm begging her to roll over so I can clean her up.
I had asked the previous resident for some pain medication to calm her down, but because of her altered mental status he didn't want to go that route. Since then, the residents had switched off, so I went to the doc with eyes brimming, BEGGING for medication to calm her down. After 50 mcg of fetanyl and 1mg ativan she was finally FINALLY starting to relax.
Her family came out to the desk, and stopped to see me before leaving. "Thank you so much for your patience with her. She's not like this. She's a CNA, she keeps herself clean, she drove herself to her chemotherapy appointment yesterday! We don't know what's going on but you've been wonderful and we really and truly appreciate the way you handled her."
And that made it all worth it.
TL;DR: Some patients need our patience
-K
I had this 45 year old woman with cervical cancer, currently receiving chemotherapy, chief complaint of altered mental status. She was a hot mess. She wouldn't sit still, was writhing around in her stretcher, non verbal and not following commands. I could tell she was uncomfortable, and was understanding what I was saying, but was just in so much pain she couldn't listen. My patience was waning as i struggled to complete the simplest of tasks to figure what was going on with her. I had a tech hold her down while I accessed her port to draw labs. I hung fluids but she kept getting tangled up in the line. I couldn't get an accurate blood pressure because she wouldn't leave her arms still long enough for the cuff to inflate. She needed CT scans but there was no way she could lay still enough for her to do the imaging. She kept getting out of bed, and 3 family members and I had a struggle to coax her back in. I cringed every time they came to the desk, because I knew it was going to be another ordeal.
I had already had a really shitty and busy day. I had her, two new patients that I had just thrown IVs in, and one ICU step-down patient that was finally getting settled. Welcome to the ER. I needed coffee. Badly. I was the floor for 8 minutes, tops.
When I get back to the desk, her family member is waiting for me, "We tried to grab you! Her colostomy bag exploded!" I rush into the room and she is now kneeling on the stretcher, elbows on the bed and refusing to budge. Theres stool covering her and the bed, and all she is doing is rocking back and forth on her knees and elbows. At this point I'm about to cry. I can feel my self getting testy while I'm begging her to roll over so I can clean her up.
I had asked the previous resident for some pain medication to calm her down, but because of her altered mental status he didn't want to go that route. Since then, the residents had switched off, so I went to the doc with eyes brimming, BEGGING for medication to calm her down. After 50 mcg of fetanyl and 1mg ativan she was finally FINALLY starting to relax.
Her family came out to the desk, and stopped to see me before leaving. "Thank you so much for your patience with her. She's not like this. She's a CNA, she keeps herself clean, she drove herself to her chemotherapy appointment yesterday! We don't know what's going on but you've been wonderful and we really and truly appreciate the way you handled her."
And that made it all worth it.
TL;DR: Some patients need our patience
-K
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