C’mon people, it is snow. It falls, sometimes it sticks, you slow when you drive, don’t act like an idiot and things turn out OK. But no, people drive like crazy, common sense goes out the window and folks get hurt.

I went to northern Arizona over Christmas and encountered real snow (yes, snow in Arizona), not this puny wannbe snow that we get in Portland. But there people acted normal, drove responsibly and everyone got home safe. Then I come home and 3 weeks later and deal with this stupidity. Oh well.

Here’s what I’m talking about:
Arizona 1:

Arizona 2:

Portland 1:

Current Weather:

Like LL said,”Don’t call it a comeback, I’ve been here for years.” But really it is a comeback. Back to mine, back to my roots, back to what is important to me. I realized that even if it would mean a pay cut, somethings are more important than money. Call it karma when an offer came through for extended severance in light of looming lay-offs. I’ve been thinking about all of this quite a bit and while I haven’t arrived at a full decision, the beginnings of a plan has emerged. If things go like I hope, big things are transpiring in the next couple of months.

Y’know how I know?  Every little bug knocks me down.  I want to sleep but can’t.  I wake up more than I’m asleep it seems.  Even with chemicals.

That said, I’m taking the rest of the year off.  I get on a plane tomorrow and head for Arizona hoping to recuperate and recharge and maybe stem the bleeding that is my will to continue as a nurse.  Burnout is a terrible thing.  So I’m going to enjoy a white Christmas in the White Mountains with my family.

Hope everyone has a wonderful Christmas and a great New Year.  I’ll be seeing you in 2012.  Promise.

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Great, I think to myself. It’s a complaint, or a problem, or something unpleasant. Prejudicial? Probably, but the way things have been lately it’s the reality. Head up, smile plastered on I head over to 32.

As I walk in I see a familiar face. He had been with us for about 2 weeks, dealing with the effects of alcoholic cardiomyopathy and most of us only gave him even odds to stay sober and in good shape. I had spent a lot of time educating, reinforcing and generally trying to help him beat the odds so it was good to see him because he looked like it all had worked.

“Hey,” he said, ” I’ve been sober now for 73 days thanks to you guys.”

We talked for awhile as he related everything that had gone on since discharge and how he had really turned his life around. It was nice to hear for a change.

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Anyone who reads the news, watches the news, or is involved in healthcare knows that diabetes is a huge and growing epidemic. Sometimes you just know they’ve been brewing things for sometime, in this case it was probably true.

Admitted with polydipsia, blurred vision and dehydration and a glucose >600mg/dl. Did I mention that multiple family members on both sides of her family tree had diabetes too? Any guesses to the hemoglobin A1C?

>15!

So far off that our machines couldn’t process how high it really was. With a little math that works out to an average blood glucose of 456mg/dl. That’s about the highest I think I’ve seen, if not ever, at least in a very long time.

“He’s a 55 year old male found down by a bystander and brought in by EMS. He’s being admitted to you for altered mental status, ETOH withdrawal, hyponatremia and chest pain. Any questions?”

It’s a common story. Passerby sees guy slumped over on the sidewalk, sleeping soundly In a drunken stupor and calls EMS. EMS comes and determines the guy is drunk as a skunk but “altered” so per protocol they bring him to the local ED. A workup by Dr. Caresalot show the altered electrolytes and altered mental status of a chronic drunk, but instead of giving him a banana bag and letting him sleep off the drunk, they admit him.

On admit labs his alcohol level is 456 mg/dl or .456 on a breathalyzer, over 5 times the legal limit. A level this high shows dedication and a long history of this kind of abuse, which means he is more susceptible to withdrawal symptoms at a higher threshold than normal. Guys like this start to have withdrawal symptoms when they hit the 150 mg/dl level, so the shakes, the autonomic symptoms, the hallucinations and agitation are starting when he hits the floor.

Ativan is given in copious amounts over the next couple of hours to control the symptoms. Then while on the toilet he has a withdrawal seizure and bradys down earning a trip to the ICU for more intensive Ativan therapy. He can’t protect his airway and aspirates while on the vent and develops pneumonia. A delirium develops during his stay in the ICU and when stable enough for the floor he needs a sitter to deal with his agitation while the delirium clears.

Every chance he is asked about quitting alcohol he states adamantly “I’m never going to stop drinking.”. So he stays with us for two weeks, detoxing him, curing his pneumonia, clearing the delirium, repleting magnesium, getting him fed, all of the healing that being in the hospital provides. So after the two weeks, with help from social services he is discharged to housing, clean and sober, ready for a new life. He then walks into the convince store around the corner from the hospital and walks out with an 18 pack under his arm to start over. And the cycle continues over and over again.

I’ve lost track of how many times we’ve done this. More times than not, a good Samaritan calls it in. Instead of minding their own business, they take it upon themselves to “help” with no understanding of the events they place in motion. Instead of leaving the drunk sleep off the drunk, they call 911 to get help. EMS is obliged then to treat and transport starting the whole series over again. I’m not against helping, I just wish people would think before they acted and our ED docs would not admit everyone who shows up on the doorstep.

First, it was a single shift. Come in, do my work, go home.

Second, I wasn’t in charge. No politics, no managing disparate personalities, no calming the irate customer, er patient. Just me and my patients.

Third, there were no chronically. Lately we have had multiple long-term patients. You know the kind, multiple co-morbidities, unruly families with unrealistic expectations, tons of meds, sick – but not acutely ill, the chronically ill, with personalities to match. After days/weeks/months of the same people, it gets old. There was none of that. It was, refreshing.

Sometimes change is nice.

Yeah, five hundred and one chances to see into the inner workings of a nurses’ mind.

Five hundred and one attempts at humor, pathos, cathartic screaming, ranting, introspection and education.

I’ve been writing a blog of some variety since nursing school, most of those older posts are lost to the Internet ether and frankly, they weren’t any good to begin with so it is no true loss. This blog has been with me though since I started at my current job, nearly five years ago. I’ve gone from wide-eyed new grad praying not to kill anyone to a slightly crispy-crittered, nearly burned out charge nurse.

So much has changed on my floor that I hardly recognize it somedays, just like I hardly recognize myself somedays. I’ve grown and this blog has grown with me. Soon, I will be into another phase of my career, new fresh things to learn, new fresh things to complain about and teach about, and I’ll be taking everyone with me. It is no longer a question of if, but when. Not yet, but I hope soon.

Thank you all for being on this journey with me. As the saying goes, “This is only the beginning.”

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In a hypothetical hospital many years ago there was an ED. Small, cramped, poorly laid out, understaffed and trying valiantly to provide “Gold Star Service” to everyone that graced their doors. For years this little ED-that-could worked their hearts out and while maybe not providing “Gold Star Service” to them all, they did the best they could and the sick and dying were taken care of.

Now for those years the poor manager of the this little slice of Hell cried out in need for many things. More staff. More equipment (stuff that worked). A remodel to improve flow and room for treating sick folks. And while other floors got staffed and remodeled, the poor little ED sat alone in it’s squalor.

When the surveyors of the Joint (smoking) Commission arrived the higher-ups would pull other staff from across Mammoth Health Care Inc. tm to ensure the illusion of competence was complete. Then, as soon as the surveyors left, things went back to normal.

This isn’t to say the care was poor. They did well in a poor situation catching many dire diagnoses and saving many lives. Yeah, not everyone got “Gold Star Service” but the vast majority made it out alive and whole again – sometimes after a stay, but saved nonetheless.

Then one day the Master, CEO of Mammoth Health comes to visit dragging behind him architects, facilities engineers, nursing vice-presidents and the entire entourage that befits one of his rank and stature. Plans are shown that would vastly improve the poor little ED-that-could. A remodel, more equipment and more staffing. Mouths gaped, had all the prayers been answered? Yes, their time had come finally.

Smarter minds thought though, “Why after all this time choose now?”. Those minds began looking and trying to figure out why now. Thanks to scuttlebutt it became apparent: one of the Master’s family/entourage had been to the little ED-that-could and had not gotten the full “Gold Star Service”. All of a sudden, it made perfect sense. They could see it so clearly now.

Coincidence? Like I said, I don’t believe in them.

More readings… Very Influential People

I wonder why new residents love to torment tele nurses?

Are we that easy of a target?

Or is it that they’re too intimidated by our drive? (True story, it was relayed to my manager that many of the 1st years were afraid of one particular charge nurse, mostly due to her breadth and depth of knowledge, but also that she was doing cardiac nursing before they were conceived.)

Whatever it is,they seem to think that the only true indication for telemetry monitoring is having a heart. Yes, true. But really does every single patient you admit truly need it?

I’ve heard some truly egregious statements with regard to this. One example is the 20-something year old with pneumonia who was tachycardic. Not SVT, not atrial tach or WPW, just straight up sinus tach with a rate in the 110′s. Gee, you think maybe that they were, A.) dry or B.) febrile? Or maybe a combination of both. A couple of days later, one of the attendings realized this and took off the tele, but the poor patient got charged the higher rate for the 3 days they were monitored when they really didn’t need to be.

Or the time there was a stroke patient on our neuro floor, probably the best place in the hospital for them, remote monitored on tele as well. “But the heartbeat was irregular.” complained the nurse to the doctor, “Shouldn’t they be on the tele floor?” Of course the young impressionable intern agreed, forgetting the patient suffered from chronic atrial fib…and had a pacemaker. The patient had been on all their normal home meds until admit and heart rate was well controlled, blood pressure was acceptable and all they were dealing with was the stroke sequelea. But out of the nice private room on neuro into a shared room on tele. Family was pissed. That was a fun one trying to smooth over.

Of course there is always the bleeders, usually GI in origin that HAVE to be on tele. I’m not talking the folks having gushing blood from mouth or rectum, but the LOL admitted with tarry stools and a slightly low H&H, or the post-surgical bleeder. The relatively stable ones. And on multiple times I hear the same refrain: we want them on tele so you can see if something happens. OK, maybe you forgot basic A&P, but really by the time we see something on the monitor, the damage has been done and they’re slip-sliding back to the ICU. Like the one last month who the nurse was helping get up to use the commode who syncopeed out and shit black stool all over the bed (luckily missing her)…guess what? Nothing on the monitor, beautiful sinus rhythm with nary a bump in rate from before. Off to the Unit they went.

It seems like everyone gets tele ordered. We’ve had a couple of new hires lately, all experienced nurses, one asked me, “So, patients get taken off tele and moved to med-surg, right?” I tried not to laugh too hard. “Nope, they stay here until they leave…”. It becomes a rote thing, just a part of the routine, not actually deciding if it benefits the patient.

On the other side are the times when you go, “What, they’re not on tele? Are you kidding me?”. Unfortunately due to the over-reliance on tele, I can’t remember a recent example of this! But it’s what comes with the territory. We take the ones that need to be on tele and theses that really don’t all the same. Because I really want the DNR comfort care patient on tele, (true story). I just wish I knew why.