My Nursey Senses are Tingling!

 UGH. So I had this post written a month ago, and me with my clumsy fingers deleted the words and it autosaved nothing. So I'm going to try to recreate what I had. Forgive me if I'm missing bits. 

The report I got from the nursing home paperwork said my patient was AAOx3, spanish speaking, but pretty much independent, only needed assistance transferring. He was sent to the ED for "lethargy, vomitx1 with dark brown emesis." 

The patient I had in the stretcher would only open his eyes to loud verbal/tactile stimuli. We used the translator phone services to get information from him, but he was unable to form cohesive sentences. There were dark brown specks on his gown. Immediately I think GI bleed, so I drop B/L 16Gs in the ACs (like a boss). However, his SpO2 was barely breaking 90ish on 4L O2 via NC.

The resident and attending were not impressed with his presentation. His basic labs came back pretty normal, but after all that time, he was no more responsive and they wanted to admit him to a med-surg floor. 

I kept insisting that something was wrong, that we were missing something. This guy was, at baseline, normally functioning, and now he was barely awake enough to speak a full sentence. 

Finally, the internal medicine resident comes down to evaluate him, agrees with me that we're missing something, and orders an ABG. His Co2 was waaaay elevated! He orders bi-pap and consults critical care.

I was so frustrated. We could have saved so many steps if the doctors had just listened to me! Ive been an ER nurse for 2 years, and I don't feel as confidant as the seasoned nurses are, but I feel like I should have pushed harder. I knew something was wrong with this patient, and when all the labs came back normal I should have pushed to keep digging. Yes, this is the doctors responsibility, but I still felt partly responsible. No harm came to the patient, but now I know for next time. I have more experience than I give myself credit for and I need to trust my instincts.

On the other hand, docs, if your nurse is concerned about something...fricking listen!I may be young, but if I'm concerned about something, give me the benefit of the doubt. 

TL;DR: Don't doubt when your nursey senses start tingling!

(also don't accidentally delete a post that was written two weeks ago...sorry if there are pieces missing!!)

-K

Rotten Tomatoes gives 5 Stars for this award winning performance

Enter stage left, patient with chief complaint:

 "I need to have my hands surgically removed. They are on fire and Jesus Christ will give me new ones." 

ohhhhkay. Are you hearing voices? 

"Not voices. Just one voice. From JesusChristMyLordAndSaviorYahwehAllahGodAlmighty"

Montage of a calm, cooperative patient being changed into paper scrub garb.

One hour time lapse...

"I decided I no longer want my hands amputated and I would like to leave"

*thorough voice-over explination why the patient cant leave the hospital*

Cue the hysterics: "THIS IS THE USA I WANT MY FREEDOM! USA! USA! USA! USA!"

Grand Finale:

 

*Nurse K takes her bow as the rest of the staff applauds*

 

 

Nurse Jedi with the 20G lightsaber

Very nice older black gentleman visiting from his home many states away forgot his COPD inhaler and comes to my ER with SOB. Medics got an IV en route but I couldn't get blood from it, so I decided to throw another one in.

While searching for a vein to hit the patient gives me the usual "My veins are tiny and they roll, they usually have to use a butterfly" line that makes my skin crawl. But he was a nice, normal guy so I didn't let it bother me.

After I easily drop a nice 20G in his AC..

Pt: Wow! The force is strong with you!
Me: Have some faith in me man! I am the Obi Wan Kenobi of IVs!
Pt: You are the Jedi Master girl! Darth Vader is NOT the Father!

We instantly become best friends, and the nurses and doctors in the next room are hysterically laughing at this interaction

Respect the Reps!

Okay, so are any of you familiar with those little caps with alcohol in them that screw into the end of any IV insertion site, as well as any y-sites on the tubing? (If not see illustration) My per-diem job is to travel around to hospitals and educate the nurses on them. Ive only done 3 hospitals so far, and I find it so very frustrating.

First of all, these caps are awesome, and I'm not just saying that because I work for the company. You put them on and when you're ready to give an IV medication or hook up IV fluids, you don't have to scrub the hub with alcohol. It also keeps any lines completely disinfected...how many times does your central line end up in the patients armpit? Unless you're scrubbing with alcohol for a full 30 seconds, germs can still get into their blood stream. These stupid little caps are saving so many blood stream infections!!

Going to the units to educate the nurses on them is super frustrating. I get it. I'm a nurse. We're busy. And you hear "nurses come to the desk for a quick in-service" and the eye rolling starts. I've heard all the excuses on why they feel like they're too busy or don't need to listen to the rep. "My patient is leaving AMA" "I'm never going to use that" "I just have so much charting to do" My whole spiel takes literally 3 minutes. I want to tell you about it and answer any questions you may have, because most likely your hospital has already signed a contract with us requiring some compliance percentage from the nursing staff. 

I've had nurses this past week yell at me because they "didn't have time", and when I came back later, I was ignored. I've had nurses yelling at me about how stupid and costly this was, and that they should get a pay raise instead of buying this product. At this hospital, we were implimenting a new size variation that now fits on the ends of IV tubing, as well as syringes. I've had nurses yelling at me because they weren't all rolled out at once.

None of this falls on me. I am here to educate you on something your hospital is mandating you use. And realistically, you're saving you and your hospital lots of time and money. But all that aside, why aren't nurses more respectful? 

I think I get so frustrated because I hold others to the same standards in which I work. Unless I was with a very unstable patient, there is nothing I am doing that cannot wait three minutes. The reps/educators that come to the floors are just doing their job, and really whatever product they come around with is designed to help me do my job more efficiently, no matter how insignificant it may seem at the time.

*Side note* I find it interesting that the units that give us the most respect, and are receptive to the education are the ICU/critical care and the ancillary units (endo, IR, etc.). Medsurg/telemetry units seem to give so much resistance for a 3 minute speech. (seriously people. THREE MINUTES)

So I beg all of you. When reps/educators come to you unit, please be courteous of them. If they show up at your 8 o'clock med pass, ask them to come back at 10 when things slow down and I'm sure they will comply. Ask them questions related to the product. Don't bitch about how stupid it seems, or how upset you are without hospital policies. Don't roll your eyes. Listen to them and move about you day. They're just trying to do their job to help you do yours.

TL;DR. Respect your reps, reduce blood stream infections!

-K

A quick word about techs

Before I became a nurse, I worked as a float critical care tech for my hospital. I went to all units, including ICU, and was trained on blood draws and EKGs. I had some nurses that were awesome to work with and some that abused the ancillary staff, and I vowed that when I became a nurse I would delegate appropriately. I would not ask the techs to do things that I could easily accomplish so I could sit on my phone. If I'm asking them to do something menial, like grab vital signs, then I really am too swamped to do it myself.

Some of our techs are awesome. They do anything I ask without rolling their eyes. They are constantly look through the charts, checking the orders to see who needs an EKG or labs drawn, and offer to do it before I even ask. They ask me who they can bring me from triage, and have them set up on the monitor before I even walk in the room. When a medic comes in, they work like clock work with the nurses and doctors. They know the airway cart inside and out and when the docs ask for weird supplies they run and get it before I can even figure out what they're talking about. 

Other techs are awful. They roll their eyes when I ask them to do something and say "I'll get to it." and I know they won't. They'll disappear. I can't count on them for anything but making sure the inventory of the patient's belongings are done before they're admitted. It will take me longer to find them and ask for help then for me to just do it myself, and put me further behind in my work.

Scenerio: We get a patient back from CT scan, hook him up to the monitor and SpO2 is 60% on room air. Obviously we're freaking out. Doctors are in the room, the plan is to preoxygenate with bi-pap then intubate. The tech is walking around the room, getting in everyones way to inventory the belongings. While the doctor is updating the wife on the plan, he interrupts to get her to sign the sheet. Then he disappears. Completely unacceptable.

I've noticed that most of the good ones are in nursing school, even if they're just working on their prerequisites they still want to further their career, and they want to be a part of the team. I know we're only going to have for a short time because once they graduate they're gone. I feel bad sometimes, because I know they're over worked. When I have a sick patient I go to them when I need help, because I know I can count on them, even if they're in another area of the department. I don't feel comfortable transporting an intubated patient to CT scan and then ICU unless I have a tech I can count on when shit hits the fan.

When I have a tech that really helps me throughout the day I make sure to let them know I appreciate it. I thank them endlessly, and they always reply with "Stop thanking me, I'm just doing my job." I've written star employee cards for them before because I want them to know I truly am thankful for what they do. If I see a lazy nurse abusing them, I don't mind stepping in to help. It's a mutual respect thing.

So If you're a tech reading this, know that we really value what you do. You make our days so much easier if we can count on you. If you're a nurse reading this, I'm sure you can attest. I think it's important to thank them for what they do, and to delegate appropriately. 

TL;DR: Techs really can make or break your day, appreciate and delegate.

-K