Do Unto Others...

   The other night I was in Phase 2 Recovery. This is typically a piece of cake gig, a short stopover before the patient gets to go home. It is kind of like working Fast Track in the ER, all about moving patients in and out as quickly and as happily as possible. You only get stable patients from the main Recovery Room, or with some minor procedures, straight from the OR. Phase 2 has recliners, warm blankets, and yummy stuff to drink. It even has a fancy menu, ie. saltines, graham crackers, and broth. Each small bay has a chair for a family member to sit and visit with the patient until it is time to go home, typically after 30 minutes to an hour or so.
   I was breaking down a chart when I heard some commotion from the other side of the room. A very experienced Recovery nurse was telling a new nurse she was going to call the doctor "right now". I walked over to see if they needed help. The patient was on a stretcher. He was a male in his 40's, vacantly staring into space. I tried calling his name and doing a sternal rub with no response. We got him on the cardiac monitor and pulse ox. He had loud, irregular, snore like respirations. I attempted a head tilt chin lift to open up his airway more. His neck and jaw were stiff and uncompliant. I noticed his sheets were soaked through with urine. A CNRA arrived, inserted a nasal trumpet and started to bag him. I got the code cart. The Anesthesiologist got there and had me give the patient an amp of Narcan with still no response. The code team burst into the room and got to work. The Intensivist and the Anesthesiologist conferred on the situation. The patient's pulse was getting fainter and fainter. The Nurse Manager walked into the bay and informed me that I was going to need to take care of the patient's crying wife.
   Holy crap. In the ER we had patient reps who sat with family members. On day shift we had chaplains.  I looked at this pale, scared woman and thought that I would rather do a thousand chest compressions than try to comfort her. So, I walked over and put an arm around her, leading her out of the crowd gathered around her husband.
   I felt completely helpless and inept. She was crying and asking me if he was going to be okay. All I could say was that the team was doing all that they could. We prayed together. We talked about how they had met. She kept repeating "I can't lose him. I can't lose him". I held her hands, and we prayed some more. I could hear them starting chest compressions. I heard someone talking about PEA and V-tach. I heard the distinct sound of a defibrillator charging. When she heard a doctor yelling "Clear", her face drained of all color and she ran back to the bay with me in tow. One of the doctors present told me to get her into another room. Not everyone in the hospital is on board with family presence at codes.
   This woman obviously loved her husband very much and started to become agitated when she was advised to step out of the area. Right at this time Dr. J walked in. He was a partner of the surgeon who performed this patient's very minor procedure. Dr. J  was on his way to Preop to see a hip fracture patient. He immediately took in the situation and acted quickly with no hesitation. He could have just passed through with no comment as another partner had done. However, he headed straight for the patient's wife. Doctor J took her hand and introduced himself. He explained to her in simple terms what the team was doing and why. He sat with her for several minutes while she cried on his shoulder. He escorted her to her husband's side when the intensivist was about to call the code. She sobbed and cried for her husband to come back to her. Doctor J held her hand and then brought her back to me when he had to leave for the hip surgery.
   The patient's wife retreated to a private room to make phone calls, with me and her husband's surgeon occasionally checking on her. The actual surgeon was deeply shaken, stating he had never lost a patient before. The anesthesiologist who had been the first doctor on the scene looked devastated. He asked me if the wife knew that they had done absolutely everything they could. The patient's wife came out briefly to let us know that she was declining to pursue an autopsy, that she wanted her husband's body "left alone". She told us that her son was on his way to get her and take her home.
    Dr. J returned to the area briefly after a very quick hip pinning. He went with the wife to see her husband's body one last time before she left the hospital. Some staff were complaining that before he took her over to see her husband, Dr. J had removed the endotracheal tube from the body. However, since no one, including the Medical Examiner, wanted an autopsy, I guess maybe it didn't really matter. I believe that he was trying to make the situation easier for her to bear. An et tube can be a jarring sight when protruding from the mouth of someone you love.
   When the adult son arrived, the patient's wife gathered her things. She asked us to make sure her husband had a blanket, that he hated being cold.
    I said goodbye with a hug and a "God bless you".
   The next evening I saw Dr. J again. I thanked him for his help and told him that for a surgeon, he was a pretty good guy. He appeared genuinely perplexed by this and asked why. When I explained how much his involvement had meant to the patient's wife, he still looked puzzled. He stated "It's what I would want someone to do for me". I smiled and thanked him again before he left for the night.

Vintage Bedpans

 I think every nurse sometime in their career, usually many times in their career, has provided a bedpan to a patient. Or held an emesis basin while it was filled up with vomit. Or at least hopefully, if the patient did not miss and get the nurse's shoes instead. The crisp white uniform and cap have (at least in the U.S.) gone out of style, but some aspects of nursing are definitely timeless.

I'm No Paula Deen, But...

These are seriously the best things I have ever eaten. I took them to my work, and they disappeared in minutes. I had never made anything from scratch in my life, but it was not even that hard. Trust me. I am no expert chef, but I love to EAT. And don't get upset that I'm promoting obesity in our already overweight and sedentary society. Just don't eat them all yourself. Share with a buddy. Moderation, people! Awesome stuff.




Symphony Brownies
Yield | 12 brownies

Ingredients
4 ounces unsweetened chocolate; coarsely chopped
3/4 cup butter
1 ½ cups white sugar
3 eggs
1 teaspoon vanilla extract
¼ teaspoon kosher salt
1 cup all-purpose flour
2 (4.5 ounce) Symphony Chocolate bars; broken into squares

Directions
1. Preheat oven to 350 degrees. Line an 8×8 inch baking pan with foil and spray with nonstick cooking spray.
2. Microwave chocolate and butter or margarine in large bowl at medium (50% power) for 3-4 minutes or until butter is melted.
3. Whisk until chocolate is melted. Stir in sugar and add in eggs, extracts and salt. Gradually add in flour and stir until just combined.
4. Spread ½ the batter into prepared pan. Add an even layer of Symphony Chocolate squares and cover with remaining ½ of brownie batter. Bake for 30-35 minutes; do not over bake.
5. Remove to cooling rack. Allow to cool completely before cutting.

Inspired by Paula Deen and adapted from allrecipes
mybakingaddiction.com

A Wiggly, Licking Homecoming

At the Holidays when you are cozy in your home with your family, remember those who are away from their loved ones doing an often thankless job, dedicated to keeping their country safe.

Alert and Oriented x 1

A patient wakes up in the Recovery Room
"Where am I" he asks.
"You are at the hospital. Your surgery is all done" I say to him.
"Where am I?"
"You're at Crazyland Medical Center" I say.
"But, where?"
"Gigantic City, Florida" I tell him.
"Is this Earth?"

The Original Christmas Story via Facebook

I hope my Non Christian friends will excuse a brief foray into the origins of Christmas, as told through Facebook. I thought this was quite clever and sweet.

Random Musings AKA Too Tired to Write Anything Coherent

Passed ACLS yesterday. Even though this is the 3rd time I have taken it, I always get nervous and am afraid I am going to fail. I feel like an imposter in there with all the ICU and Cath Lab nurses. But I actually had no trouble at all passing because the material was extremely fresh in my mind. We had the most unexpected, most draining, marathon code the night before. That is definitely a story for another day when I am more awake.

I also attempt every year to use trauma shears to cut Holiday wrapping paper. They work great on patients' clothing, but not so much on my delicate Christmas tree covered gift wrap. Go figure.


Bought the Lego Airport set for my 9 year old. 99 freaking dollars for Legos! Seriously. I ...have...lost ...my...mind. She still writes a letter to Santa, though, so it's worth working a few extra hours for some overpriced plastic blocks. You gotta be able to rely on Santa.

My 12 year old wants a cell phone. Some of her friends have had them since third grade.

After ACLS I stopped by Preop Holding as I was advised to by my Manager  "Just to make sure they don't need you. The surgery schedule is fairly light in the afternoon and evening tomorrow. I'm sure they will just send you right home". Uhhhh. Yeah. Not so much. The good news is that the Lego Airport is now paid for and then some. But every floor patient we got was starving, grouchy, on isolation and had an infiltrated IV. Fortunately everyone was stable and had a vein for me to stick, and all turned out well. One elderly hip fracture patient was scheduled to be operated on by the infamous Dr. Handsome. Fortunately his semi handsome, but extremely easygoing and kind partner showed up to perform the surgery.

Made my first ever brownies from scratch. Delicious! Have pumpkin cheesecake with streusel topping cooling in the fridge right now. Heavenly. Feeling warm and blessed to be home with my family.

It's Not All Sunshine and Lullabies

   -L & D is not always the happiest place in the hospital. Consider the case of Ms. H. Ms. H is a healthy 35 year old female, at 28 weeks gestation with her 3rd child. Thus far the pregnancy has been uncomplicated. One Friday morning, on her way to work Ms. H notices that the baby, a girl, is not moving as much as normal, so she calls her OB and arranges to come by for a quick check. Ms. H's BP is up and her weight has gone up several pounds, much of which appears to be edematous. The doctor checks the fetal heart rate, which is 127. He offers her the option of going to the hospital for an ultrasound, which Ms. H accepts. The hospital can't get her in for several hours, so the office nurse advises Ms. H to go home and try some caffeine to get the baby moving.
    After waiting at home and still not feeling the usual amount of fetal movement, Ms. H drives herself to the hospital for the ultrasound. When the tech begins the ultrasound, she quickly stops and steps out to answer the phone, stating that the secretary is gone for the day, so she has to help at the front. The tech is gone for an unusually long time. Finally the tech comes back in the room accompanied by Ms. H's OB. Ms. H immediately bursts into tears, sensing that whatever is coming is going to be unbearably painful. The MD takes her hand and simply says "It isn't good". The baby was dead and possibly had been dead for quite some time. The doctor gives Ms. H some options. She can go home, pack and come back the next day for induction of labor or she could go up to the floor immediately to start the process. He explains potential complications: infection, bleeding, DIC. He offers to order her Ativan and Ambien. Ms. H decides to go up to the floor for immediate induction.
    The OB accompanies Ms. H upstairs and promises to call her husband, as she is still quite tearful. The doctor leaves to go write admission orders. Elizabeth, a veteran L & D nurse from Ireland, appears and gives Ms. H a hug. She gets Ms. H settled into a room, obtains a urine sample, and applies the ID bracelet. Soon it is shift change. Stacey, another veteran L & D nurse, introduces herself to Ms. H and hugs her also. Stacey inserts an IV and draws blood in a rainbow of tubes for stat labs. The OB returns and inserts Cytotec into the vagina to initiate the induction process.
    The lab results come back quickly. Ms. H's white count is high. Her platelet count and RBC's are slightly low, and her liver function tests are abnormal, not the best findings. The OB orders two IV antibiotics to counter any infection that is present and then  leaves the hospital for the night. Ms. H's husband arrives amidst more tears. The nurses contact a representative from a local support group for parents of stillborn infants and infants who die shortly after birth. The representative will later come visit Ms. H in the hospital.
Because of their other children, Mr. H has to leave for the evening. Stacey gives Mrs. H an Ambien and checks on her periodically throughout the night.
    In the morning an infusion of Pitocin is started by Elizabeth, who has returned for the day shift. Elizabeth also hooks up a Dilaudid PCA, so that Ms. H will have some pain control. Ms. H is alert and oriented and occasionally tearful. Her spouse stays with her throughout the day. Elizabeth assist Ms. H in filling out the forms required for a death certificate. Ms. H names the baby Anna Elizabeth. As the day shift goes on, contractions begin and eventually grow stronger and more painful.
    When the night shift staff comes on duty, Stacey returns along with a new grad RN, Candace, to take over care for Ms. H. The PCA is no longer providing sufficient pain relief. The nurses suggest an epidural, to which Ms. H readily agrees. Sheila, the charge nurse, comes in to help set up for the epidural. The Anesthesiologist arrives and coaches her CRNA student through inserting the epidural. Ms. H relaxes considerably once she obtains adequate pain relief. The OB returns and decided to do an amniotomy, breaking the water. Once the doctor leaves, the contractions increase in frequency and strength. Stacey, Candace, and Sheila all are present to deliver the stillborn baby.
    The nurses whisk the baby's small body off to the next room, where they clean her and wrap her in a blanket. The nurses obtain her handprints and footprints. They put a hat on her head and take photos of her. Then Stacey and Candace take the baby to her mother.  Tears stream down Mrs. H's face.  Ms. H holds her baby and looks at her lovingly for a very long time as if trying to take in all the details and commit them to memory. The baby has fair white skin and lots of dark hair. Her eyelids are still tightly shut.
Eventually the nurses take the baby back, and Candace takes her body to the morgue. Stacey gives Ms. H an Ambien. The OB arrives back at Ms. H's room and delivers the placenta without complications. Ms. H's husband returns home to their children. Stacey and Candace pop in at least hourly throughout the rest of the night to assess Ms. H's mental and physical status.
    In the morning RN Elaine takes over Ms. H's care. Elaine has been in L & D for 30 years. Ms. H's husband and other two children are present at the bedside. Ms. H requests a chaplain to pray with them. Elaine asks if she would like the baby present for the prayer. Ms. H considers this and agrees, stating "Maybe it is the only thing I will ever be able to give her".  It is a Sunday, so the main hospital chaplain is presiding over mass at his home church. Elaine calls and calls, everywhere she can think of. There seem to be no available ministers anywhere in the entire metropolitan area. Eventually a tall, bald man wanders into the room, introducing himself as one of the hospital's assistant chaplains, stating he had just stopped into the office for a moment and saw the message. Elaine brings the baby to the room, and the chaplain and  family hold hands and pray. The two other children, 7 and 9, appear interested in the baby and both hug her. The chaplain leaves, and Elaine returns the body to the morgue,where an autopsy will eventually be performed. Elaine Brings Ms. H a decorative box, which contains a sympathy card signed by the nurses, the baby's blanket and hat, copies of the footprints and handprints, as well as the photos. Ms. H is discharged to home at approximately 1500. -
   
    These were some damn good nurses, who did their utmost to make a horrendous, heartbreaking situation at least somewhat bearable. I was not one of the nurses this time. In fact, I was the patient, Ms. H. Being the patient totally sucks, but when overcome with grief, it is excruciating. Those nurses gave me 100% and I took it greedily and gratefully. Now when I give a hug, hold a hand, or look in a face contorted with grief and pain, I draw on what those L & D nurses gave me in the midst of my deepest, darkest moments. Their love and compassion flow through me to my patients as though from a well that never run dry.

    **One year and 3 months from the date of the loss of Anna, I gave birth to a healthy 9 lb baby boy.
Life is good**

Is It Just Me?

I used to eat no red meat...until I married my husband. He loves steak, hambugers, roast beef, ground beef, beef of all sorts. So, I learned to prepare dishes with various forms of red meat. I noticed something. It hit me very strongly today as I opened a package of steaks to marinate. Is it just me or does raw beef just slightly give off a hint of fresh GI bleed smell? Ewww.

Really?

Was it really necessary to put a 95 year old under general anesthesia and perform an exploratory laparotomy just to dignose a fecal impaction? Just asking.

What an Interesting Hospital!

Awww....poor Jane.

Hugs And Kleenex

When I was working as an ER Tech during nursing school, I had the pleasure of meeting a great nurse named Johnny. Johnny had immigrated from Laos as a child and had a great perspective on life. The night I met him we were struggling with an elderly lady who had a severe reaction to Phenergan. She was post fall and having nausea, so the Dr gave her Phenergan, which immediately made her totally crazy and extremely strong. My job was to take the combative patient to CT, put on a lead apron, and make sure she stayed still for the scan. In addition, I was charged with keeping her grown daughter calm. Johnny watched me and talked to me about it during a smoke break: he smoked and I listened to him talk. He said that he could train a chimpanzee to put in a Foley or start an IV, but compassion was not so easily taught. He told me he thought I would make a good nurse, precious words for a nursing student discouraged by intimidating professors.
At times I think compassion is underrated, sometimes even disdained. Nurses can often be sarcastic and snarky when we talk about supporting patients emotionally or bonding with patients. I've gotten the "Well...I wish I had time to just sit and listen to patients talk, but I'm busy actually giving care" from other nurses, as if all I do is sit around and chat and neglect my other duties. We are of course encouraged to be nice and empathetic in nursing school, but also to keep a professional distance. As NurseXY mentioned in a recent blog, this professional distance is taught early on in order to ensure that our decision making abilities are not clouded by our closeness to the patient. I can see the point, but I think, as he wrote as well,  for many nurses it is sometimes impossible not to get emotionally close to a patient, especially if you are dealing with them in a setting where they are with you for weeks or months.
I have worked in ER, Preop, and PACU, places where we are with patients for a matter of hours, not days. However, we are with them at such a vulnerable time, where emotions are heightened considerably. We have interactions that I will certainly never forget.
Just this past Friday I was present when an elderly woman had a conversation with her daughter, son, and pastor debating whether to have surgery or if it was time to just stop fighting. All I did was provide the Kleenex and some hugs, but it was a privilege to witness the love and strength of this family.
That same day I took care of a man who came directly from his family doctor's office to the hospital to have major stomach and colon surgery, definitely not how he had been planning to spend his day. He was keeping up a stoic appearance. His wife walked over to the side of the room to use her phone to notify family members of the situation. I noticed that she had stepped over to the entrance of the unit to where the curtains were blocking her from her husband's sight. She was quietly crying. I went to her with Kleenex (again). She told me that she was just in shock and could not imagine losing her husband. I hugged her and just listened. It is an honor to help hold people up in their time of crisis and need. I am in awe of the fortitude of so many of these patients and their families. If I can provide just a tiny bit of support, just a little bit of warmth to help fuel them through this incredibly challenging time, I am privileged beyond belief.

Dr. Handsome Throws Another Fit

I had hoped that Dr. Handsome's tantrum, about which I wrote earlier, would turn out to be a rare occasion, a brief moment of temper not to be repeated anytime soon. Yeah, I was wrong. The last time I had encountered the pretty to look at Dr. Handsome had been in Recovery. This time it was in Preop. He had a patient with a hip fracture, a gentleman in his 80's. The patient was on an Amiodarone drip and had pacer pads on. His telemetry nurse walked down with him, which typically only the ICU nurses do. This guy obviously had some cardiac issues. Dr. Handsome had requested a Cardiologist consult for cardiac clearance, covering everyone's butts if this guy had problems during surgery. Well, apparently the Cardiologist's report was too ambiguous for Dr. Handsome. It simply stated that the patient was a surgical risk. He threw down the chart with a clatter and started raising all kinds of hell at any nurse within his visual range. He demanded that a nurse get the Cardiologist on the phone, so we did. The Cardiologist seemed genuinely befuddled by the conflict. Finally Dr. Handsome had to get on the phone and ask for a more specific endorsement of the patient's suitability for surgery. His voice and manner did get slightly nicer while he spoke with the other doctor. Dr. Handsome then ordered that a nurse get on the phone and write down word for word the cardiologist's statement because of course he could not lower himself to write them down himself. So I wrote down. "Patient is cleared for surgery however presents significant cardiac risks". Apparently this satisfied Dr. Handsome's cover his butt instincts. He examined the order sheet (I guess just in case I had mischievously written down something different), threw down the chart AGAIN, and stalked off to the mysterious realm of the surgeons' lounge. The patient made it through the surgery.

A Calling or Just a Job?

Have you ever had a really crappy shift where you couldn't find a vein if it slapped you in the face, the patients just get sicker, the pyxis had none of the meds you needed, the lab took hours and hours for stat orders, the docs were grouchy, etc. Yeah. I had one of those a few days ago. Days like this make me question if I am just too lousy a nurse to be in this profession even though I usually love it so much.

With apologies to my atheist friends, I truly believe God/Higher Power/Universe always knows how to make up for this garbage kind of day. The next shift I had some of the sweetest patients. The docs were not troublemakers. The lab was super quick with results. And the pyxis was well stocked with all the necessities. I actually felt semi competent. I had a patient's mother thank me for being a blessing to their family. Wow :)
One thing that really struck me was when a patient's daughter, a hospice nurse, told me she was thankful that her mother had gotten a nurse for whom nursing was a "calling" not just a job.

I really appreciated that comment, but it made me wonder. What is the difference between a calling and just a job? I have wanted to be a nurse since I was a child, but know many nurses who went to nursing school to please parents, to retrain after their factory job went away, or to have a way out of a bad marriage. They are excellent nurses. I certainly enjoy getting a paycheck. I don't think I would want to be a nurse for free. I do get a deep personal satisfaction when I can make a difference in someone's life or even just provide some comfort when it is needed.  What is nursing to you, a calling or just a job?

Pulseless Electrical Activity

Courtesy of Wikipedia -Pulseless Electrical Activity or PEA (also known by the older term Electromechanical Dissociation or Non-Perfusing Rhythm) refers to any heart rhythm observed on the electrocardiogram that should be producing a pulse, but is not. The most common cause is hypovolemia.
The approach in treatment of PEA is to treat the underlying cause. These possible causes are remembered as the 6 Hs and the 6 Ts.

• Hypovolemia
• Hypoxia
• Hydrogen ions (Acidosis) *****
• Hyperkalemia or Hypokalemia
• Hypoglycemia
• Hypothermia
• Tablets or Toxins (Drug overdose)
• Cardiac Tamponade
• Tension pneumothorax
• Thrombosis (Myocardial infarction)
• Thrombosis (Pulmonary embolism)
• Trauma (Hypovolemia from blood loss)

A patient in their 50’s had been in our ER all day with abdominal pain. The person was finally rushed to surgery after 5 liters of IV fluids, and a levophed drip could not get their blood pressure out of the toilet.
A large length of gangrenous, dead bowel was discovered during the lengthy surgery. It was removed and a colostomy was made. The patient came to Recovery with much better blood pressure.
Although the patient was on a ventilator, we noticed they were starting to look a little blue.   They had a normal looking rhythm on the monitor. However the pulse weakened and then stopped. PEA. Call a code. Start compressions.
It turned out the patient was extremely acidotic*** and ended up getting 4 amps of bicarb in addition to the 2 during surgery that they had gotten. A pulse returned. Not out of the woods for sure, but able to go to ICU at least. I checked when I came in the next evening. The patient was still alive.

A Pain in the Butt

"As soon as I leave here I'm going to St. XYZ's ER. If they tell me something different, I'm gonna sue. I'm on Medicaid so I can go to every ER in this city if I want to".

-My ER patient, who was told that his hemorrhoid did not require immediate surgery, but was instead advised to try a 2 week regimen of topical ointment and sitz baths before a follow up appointment with the general surgeon.

Bullet Lodged in Heart

When You Gotta Go...

Ten hours into her shift, Nurse Nancy finally has a few seconds to run to the bathroom...

Bringing Patients Back...Good Times

Good times on the night shift. Another You Tube classic.

Dr. Handsome Throws a Fit

I transferred from the ER to Preop holding and Recovery almost a year ago. I have come to appreciate the ER doctors I worked with, the vast majority of whom were quite competent, respectful, and team oriented. On occasion we would deal with surgeons in the ER, but these were typically fairly brief encounters. Now that I am working with surgeons on a daily basis I have learned that these guys (they are predominantly male, at least at this medical center) are a different breed. Even the "nice" ones can be jerks. The other day I literally had to step into the restroom for a moment to keep from crying, something I had not done since being on orientation right out of nursing school. 
I am starting to toughen up though. Witness the case of Dr. Handsome. I had heard of Dr. Handsome in the ER, but had only met his partners not him. An orthopedic surgeon, Dr. Handsome has women talking about his good looks throughout the entire hospital. I could not wait to see this guy.  His photo in the hospital directory was distant and grainy, not giving a clue as to what this Adonis looked like. I was working in preop and had a patient scheduled for a hip fixation by  Dr. Handsome. I waited with baited breath. To my disappointment it was only his Fellow that showed up to mark the patient's hip and sign and fill out the dozens of forms that spell out repeatedly exactly what the surgery is, who the patient is, and which limb is being repaired. The woman went off to surgery and I assumed it would be another failed attempt to glimpse the famous Dr. Handsome.
To understand this story I have to explain the computer system where I work. We are in the process of moving from an old outdated system to a more state of the art one. So, our tasks are scattered between both systems and then a third system that is just for the surgical area. So just keeping track of the various passwords is a pain, much less remembering how to do everything. So, this lady has been in surgery for over an hour and one of the OR nurses runs out wanting to know how to print out a medication reconciliation form, a fairly new required form, which allows the surgeon to see the patient's list of home meds. Then he can  specify on the form which if any of these drugs should be continued in the hospital. I tried to explain the process, and she left. Then I received a frantic call from my friends in Recovery. They said the OR nurse was unable to print it out and asked me to do it. So of course at this time the Preop computer decides not to cooperate. So I rush over to Recovery to use their computer.
I walk in to see Dr. Handsome. I knew it was him. He was so gorgeous in his surgical green scrubs. However his beautiful face was in kind of a snarl. He was ranting on and on threatening to call the Nursing Supervisor. Apparently when no one printed out his form in a timely manner, he started spewing threats. He insulted the staff's intelligence a  few times while I got into their computer. He continued to threaten to call the nursing supervisor. "Maybe SHE could figure it out" he said. I finally managed to print the damn thing out and hand it to him. He calmed immediately. "Thank you" he said.  He continued writing on the chart. HE WASN'T EVEN DONE with his notes. He had been yammering on and on about how we were delaying him and he was not even done with his other charting. Then when he got what he wanted he was instantly pacified. It reminded me of my 1 year old child. Like he was threatening to call his Mommy, the supervisor, if he didn't get his treat and then immediately settled down when he got his candy or blanket or binky or whatever. I just had to laugh (to myself of course). I think from now on when a surgeon is spewing threats or dissatisfaction, I will picture him as a little one year old having a fit and smile to myself.

Oh Dear

Typical RN Problems

Hit Man: Outta the way! There is a contract out on him

Nurse: No! This man is my patient. To shoot him you'll have to shoot me first.

Hit Man: Have it your own way sister!    *******


Yeah...this happens to me at work allll the time.

It's Not a Freaking Spider Bite

When I first started in the ER, I was surprised at how many patients came in every shift with "spider bites". These bites seemed to have a special affinity for the buttock, breast, and armpit areas and tended to be teeming with pus. The patients usually insisted that a brown recluse spider had bitten them. Eventually I figured out that these were not in fact spider bites. They were abscesses caused by a staph infection, usually MRSA. The doctor or nurse practitioner would cut open the abscess and push, prod and dig until all the visible pus was evacuated. I learned how to properly irrigate, pack, and dress the ensuing wound, then hand the patient their prescription for Bactrim.
After a while as I became a more jaded RN, I started to get annoyed with the patients who were adamant that they had been bitten by a spider and were often quite offended and insulted at the insinuation that they actually had a staph infection. Apparently other staffers were getting tired of it too. One of our docs (my favorite) copied a news article and tacked it up in the wating room. It was about the geographic location of the brown recluse spider, ie. nowhere near where we were. Patients would still leave shaking their heads and insisting that the doctor had misdiagnosed them and their "spider bite".
Now I am out of the ER and in the surgical area. I assumed there would be no more spider bites. However, now patients coming in for an I and D of their abscess under anesthesia are telling me about their spider bites preoperatively, as I start their IV Vancomycin.
I had to roll my eyes the other day as my family was watching the show Dr. G on Discovery Health. Dr. G, a Medical Examiner in Orlando, Fl was describing the events leading to the death of her next subject. As soon as I heard the words "he was concerned about a spider bite on his back", I was like "For God's sake, Dr. G. You don't even have to do an autopsy. he died of MRSA". My kids were so impressed when the report of autopsy backed up my hypothesis :) The young man had neglected to see a doctor for his fever and malaise, not linking these symptoms with his "spider bite". The poor guy died of a treatable infection.
I hope I don't sound too much like a bi%$#, but just a little vent.

Man's Best Friend

Ok. This is not about my usual passions, nursing and food. This is another love of mine, dogs. I have a dachshund who is a spoiled princess, no not even a princess...she is the queen. I lost my beloved German Shepherd a year ago and still miss having a big dog around. A coworker who knows my love of big dogs offered me a dog she rescued 5 months ago. This nurse is moving into an urban apartment in another part of the country and is getting rid of both of her dogs :(  This dog is roughly 6 months old,  housetrained, up to date on shots, loves other dogs and kids, travels well, knows basic obedience, and loves to go on walks. She is also very cute. Perfect, right? Well, I'm not sure. I have a small child, and this dog is possibly a pure bred Pit Bull. I have heard all the stories of kids being mauled by Pit Bulls. I have also met people whose Pit Bulls would lay down their lives for the children of the family. I am very confused.
When I worked in ER and Urgent Care, I took care of many patients with dog bites. I never took care of any mauled by Pit Bulls. Maybe because they were in the morgue already? Sorry that is bad nurse humor. I met many people bitten by Chihuahuas. Seriously. The worst bites I ever saw were from a Golden Retriever of all things. Of course the lady waited a few days before seeking treatment, so the wounds were grossly infected, needing debridement and packing of pretty much her entire leg.
I really need some input on this. I have met the dog before, who seems very gentle and sweet. Is the backlash against these dogs justified? I would certainly get her spayed and never subject her to cruelty or dogfighting. Please tell me your thoughts.

A Weighty Matter

No offense meant to anyone, but as long as obesity, especially morbid obesity, is common, I will always have a job. I am the first to admit that my body is not perfect. I could stand to lose 5 to 10 pounds. I often eat too much sugar and processed foods and get too little exercise. However, it is the population that is 100 or more pounds overweight to whom I am referring. We have had to acquire special hospital beds for the morbidly obese, special wheelchairs, special operating room tables. We have one orthopedic surgeon who has literally made a fortune providing knee replacements to obese patients. We take care of so many people having toes feet, legs amputated because of obesity related diabetes. I am fortunate to have only gotten a few aches and strains from lifting/maneuvering obese patients. I have had coworkers develop severe and chronic back, neck, shoulder, and elbow problems from assisting super heavy patients. Many of these patients are on Medicaid, so everyone else is collectively footing the bill for their numerous medical procedures and quite extensive care. These patients are getting younger and younger. The other day I had a 24 year old female patient who literally could not wipe her own butt. When I asked her what she did about it at home, she replied that her husband did it for her. I have seen ICU patients with trachs for an inability to maintain their own airway and breathe solely due to their morbid obesity. My uber conservative husband makes statements like "Oh, just cut off their food stamps". Somehow I don't think that would get the job done. I don’t know what the solution is. Do you?

Food History

If I were a 1950's woman, would this look appetizing to me? Would I be recommending it as a healthy meal choice? My 75 year old Dad loves Veg All.

Cool

Things like this reinforce my belief in a higher power. It was the middle of the night in Recovery . We had 2 nurses tending to a patient who had just come out of a complicated emergency bowel resection and was going south very quickly. She was feverish and having respiratory distress. Of course not being able to breathe well was scaring the patient. Adding to the anxiety was the fact that she did not understand the English being spoken to her. She was a native of Haiti and spoke only Creole. No one could locate a patient rep who spoke Creole. Her family had gone home to rest. She was crying, making her struggle to breathe even worse. The Respiratory Therapist was setting up a ventilator. The anesthesiologist was preparing to start a central line.
 A housekeeping supervisor interrupted the chaos, politely asking if we would be there much longer- the floor needed waxing- and if we had any additional needs for housekeeping to address. This man had light brown skin but no trace of any accent. One of the nurses looked up from the gasping patient.
“You don’t happen to speak Creole, do you?” she asked in a semi sarcastic tone.
“As a matter of fact, I do” he replied.
Holy crap! We had a translator dropped into our laps. He spoke to the patient in soothing tones. She lit up upon hearing her native language. He explained to her what we were doing and why. She immediately calmed down and her oxygen saturation went up several points. When her anxiety lessened, her breathing improved. No vent needed after all. The central line was put in, and she was taken to the ICU.
Cool.

My New Favorite Book

I have not had a chance to read this book, but it is obviously awesome.

Earphone

OUCH!!!!! Wouldn't a Bluetooth be easier?

Frustration and Gratitude

Some days I come off of a nursing shift feeling like a total moron. I guess that is what happens when you try a new specialty. Hopefully my coworkers and managers will not judge me to be an idiot and will understand that I am teachable. I just need to learn how to do things that I have not done before and as a result, sometimes look stupid to others. So, some shifts are a challenge. However, I must say that the patients make everything worthwhile. The names fade, but the characters drift in and out of my memory:
The risque joke making, 60 something year old gentleman who joked that he wanted me to bring him a rum and coke with his percocet. He was in for terrible COPD and was a major smart ass with an obvious glimmer of intelligence, who turned out to be a former police chief of a nearby major city…
The occasionally confused woman with a broken hip who told me about her childhood during World War II. She had been visiting her relatives in Germany when the war broke out and and was stuck in Germany for the duration. She painted an incredibly colorful picture of the bombings and destruction that she witnessed. When she finally got home to the US, she had not seen her Dad in several years. She described their reunion with tears in her eyes…
The 75 year old woman with congestive heart failure who talked about her 40 years as an ER nurse. She said she wore a huge white cap and was required to stand when a physician entered the room. I was secretly thrilled when I overheard her tell a friend that she had a “brilliant nurse”.  She told me she raised 4 children, 3 of whom turned out to be nurses as well.
The elderly gentleman in for dehydration related to nausea and vomiting from chemotherapy. He talked about being a prisoner of war in Italy in World War II. Then he came home to Florida and started a successful dairy farm in what is now an urban area. I asked him how he felt about selling his land, and with a twinkle in his eye, he told me that it was worth it when he was able to buy his wife her first diamond ring after 35 years of marriage…

I may have to look stupid and ask some dumb questions sometimes, but really...it is quite a job.

Another 12

Off to work to heal the sick! Or at least not make them any worse :)

Scrubs, Caps, and Aprons

I was so envious of the students in the other local nursing programs. Some wore white scrub pants and blue polo shirts. Some wore burgundy scrubs. Students in my program were stuck in a time warp. White polyester high waisted pants with the seams down the front of the legs. A polyester white shirt with a zipper down the front and a peter pan collar. The finishing touch was a blue and white striped "pinafore", apparently a fancy name for an apron. The whole thing came together into an unflattering package.We did have white caps, but were not required to wear them. They did not have the black stripe. Is the black stripe an indicator of graduation? Does it indicate your school? I don't know.
The women in this picture gave me a smile. the two in dark colors are apparently students.  I love the cap of the one in the middle with the Jackie O hair. It looks like it could easily kick the asses of the other two caps.
Thank goodness we don't have to wear whites now. Giving one patient charcoal would ruin the look.  At our hopital we just went to one uniform color for all RN's and LPN's. Respiratory, PT and CNA's, etc have their own colors.What do you think of uniforms?

Had a Bad Day?

Medical Terminology

Sometimes nurses get sent to work on unfamiliar units due to staffing problems. I know little about Gynecology, but apparently they just needed someone with a nurse's license who had a pulse. So, while floating to the Gynecology floor a few weeks ago, I met a sweet as can be twenty something CNA/Tech. She came out of a patient’s room and asked me in an exasperated tone “We don’t have sanitary napkins, do we ?”
I replied “Yes, I'm sure we do. They're probably in the Supply Pyxis”
“Really?” she said ” I’ve never seen those here.”
Wondering how a Gynecology floor could possibly stay running without an ample supply of sanitary napkins, I asked  “Are you sure you know what sanitary napkins are?”
She looked at me in disbelief “Of course I do. They are the little square wet wipes like you get at a barbeque place.”
We had a quick lesson on feminine hygiene products that evening.

How to End a Life

These are the words of Dr. Atul Gawande, a general surgeon and writer.
“Recently, while seeing a patient in an intensive-care unit at my hospital, I stopped to talk with the critical-care physician on duty, someone I’d known since college. “I’m running a warehouse for the dying,” she said bleakly. Out of the ten patients in her unit, she said, only two were likely to leave the hospital for any length of time. More typical was an almost eighty-year-old woman at the end of her life, with irreversible congestive heart failure, who was in the I.C.U. for the second time in three weeks, drugged to oblivion and tubed in most natural orifices and a few artificial ones. Or the seventy-year-old with a cancer that had metastasized to her lungs and bone, and a fungal pneumonia that arises only in the final phase of the illness. She had chosen to forgo treatment, but her oncologist pushed her to change her mind, and she was put on a ventilator and antibiotics. Another woman, in her eighties, with end-stage respiratory and kidney failure, had been in the unit for two weeks. Her husband had died after a long illness, with a feeding tube and a tracheotomy, and she had mentioned that she didn’t want to die that way. But her children couldn’t let her go, and asked to proceed with the placement of various devices: a permanent tracheotomy, a feeding tube, and a dialysis catheter. So now she just lay there tethered to her pumps, drifting in and out of consciousness.”

Read more http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?currentPage=2#ixzz0yxLtNH1R
This is an excellent article that I would encourage anyone to read. Most nurses are confronted with dying patients and their families. Every day we see patients come into our operating rooms at the last part of their lives. I was very saddened last week to see a 95 year old patient no longer able to take food by mouth, with advanced Alzheimer’s, come in for debridement of pressure ulcers on the backs of both ankles and on her tailbone area. She is in constant pain due to osteoarthritis and has emphysema. Her family has kept her at a full code rather than DNR status and insisted on feeding tube placement. The pressure ulcers are from not being able to move herself in the bed. Even with excellent nursing care, pressure ulcers can eventually occur. Now don’t freak out. I am not advocating euthanizing the elderly. We give our end of life patients loving and respectful care no matter their code status or the attitudes of their family. But where do you stop adding treatments? I don’t know what the answer is.
Dr. Gawande advocates early hospice care in his article as well as educating the patient and family on end of life care EARLY in the disease process. He questions the excessive costs of extraordinary measures to keep terminal patients alive. I would be interested to hear the opinions of those not in the medical field, so I can understand some different perspectives. After years in the ER and surgical areas, jaded is a kind adjective to describe us sometimes. What do you think???

Not So Silent Killer

I had an absolutely lovely patient who was getting ready for surgery. However, I noticed her blood pressure was extremely elevated, 176/109. Considering it should be under 140/80, this is an issue. Anesthesia is hard on the body even without the strain of high blood pressure (hypertension) on the heart and other organs. The anesthesiologist ordered multiple doses of IV blood pressure lowering drugs, drugs that dilate the blood vessels, pain medications, antianxiety medications. We gave this woman a ton of medication, and her bp was now up to 192/116, possible stroke territory. Her surgery was cancelled and she was admitted to the hospital for cardiac workup and to get that bp under control. I brought her a turkey sandwich and ginger ale, as she had been fasting for surgery and quite hungry . She was very appreciative and ate it all. I gave her the lecture on how she needed to watch her diet and take her prescribed medications and how hypertension is the silent killer causing irreversible damage to the heart and kidneys before people even take notice. She nodded and said all the right things. She gave me a big hug and thanked me for her care. I went and gave her nurse on the floor a detailed report about the patient and her orders from the physician. When I came back to the bedside, my sweet patient was eating a ginormous Whopper with cheese and large fries. Now I am the first to admit my diet is not perfect, but really. Does anything we ever say make a difference? I hope she will get better.