A Little Bit of Sunshine

Every now and then I run into a patient that reminds me why I do this job.  It’s not the ones that we save, the ones we see over and over again, the ones who are generally pleasant, polite and just nice, but one who manages to touch that part of you that lives behind the wall that so many of us put up to stay detached and uninvolved.  That remove becomes so ingrained that it is a reflex.  So often we shy away from letting our patients too close for fear that something untoward might happen.  Maintaining our professional distance is a survival tactic in our increasingly chaotic work world.  Many times the ones that say, “Thank you.” and truly mean it are those that break the wall.

In our age of patient satisfaction scores, core measures, Joint Commission surveys, evidence-based practice and the overall stress of caring for the sick and dying it gets a bit dark, like the light on an overcast day.  It’s still light out, but the clouds filter it down to a dull gray glow.  But that simple act of saying “Thanks,” can make the sun come out.

My patient the other night was one such person.  As I introduce myself, I hear the words so many of us dread, “I remember you!”  Immediately my mind starts turning, rooting around in the dark recesses trying valiantly to match the name, the face and the situation of where I know him.  But I can’t.  It’s blank.

“That’s great,” I reply, “No offense I can’t seem to remember you though. “  And it’s true, I’ve drawn a complete blank.  Usually I have a pretty great recall of the patients I have taken care of, but not tonight, not even now.  “I’m hoping I did OK.”  I finish.

“Oh yeah!”  he enthuses, “You were great.  You took care of me when I was here for 20-some odd days with my valve surgery.  It’s good to see you again!”  Slowly the details are starting to come back, but really nothing.  From there I go into the normal nursing things as we chat.

Through the night he tells everyone that will listen how awesome our floor is, how dedicated and talented our docs are and how great of a nurse I am.  I bring in a pair of my nurses to hear his mechanical valve and he says, “Y’know, Wanderer is really great!  A number 1 nurse!” as they listen to his clicking heart.  I wink at him and say, “OK, how much do I owe ya’ for that one?”

The next evening as I come on and get report, the off-going nurse says, “He is so glad you’re back.  I told him I wasn’t sure, but he said he sure hoped you were!”

Sure enough when I walk in, he’s got a huge grin that I’m back.

So through the night we continue to chat.  He tells me how he thinks that our team, the physicians and the nurses at our hospital are amazing, that he wouldn’t go anywhere else for his care.  Compared to so many of the folks we have taken care of lately, who pretty much hates us, it is a needed breath of fresh air.

Finally in the morning as I do my final rounds before heading out he says, “I just wanted to say it was a pleasure to have you as my nurse,  thank you for all you do.”

I grin, turn and say, “No, the pleasure was all mine.”  as  I walked off the unit with a bounce in my step, a small bit of faith in humanity restored.

One Shift

I stumbled upon one nurse’s account of day in his life and thought, “Hey, I could do that too!”  Not that my days are all that interesting, but it’s good blog fodder.  The big difference is that I work nights and kind of see myself as a “clean-up batter.”  Original stories here: New Nurse Insanity.  via A Day in the Life of a Nurse.  Here goes…

1500: Wake up with a start, stare at the clock until my eyes focus enough to make out that it is on 3 o’clock.  Roll over with a sigh and try to go back to sleep, trying to ignore the bright sunlight outisde my bedroom window.

1615: wife comes in to make sure I’m awake, as she’s doing so the alarm clock goes off, again.  Crawl out of bed, last night really kicked my but, 5 admits, down 1 nurse and I’m feeling it in my back today.  Shower, find scrubs and load to-go bag.  Add a pair of Tylenol to my normal “morning” meds.  Feeling human, kind of.

1640: Downstairs to eat.  Hmmm, it’s looking pretty bare, guess we need to go shopping.  Add that to the list of things to do.  Eat, top off waterbottle, grab lunch, to-go bag and head for the garage.

1715:  Out the door with my bike.  My wife and I walk to end of the block and talk about our days.  She asks how last night was and sympathizes with my tale of woe.  Start riding my bike to the train station.

1725:  Dumbass in a hurry nearly sideswipes my off the road.

1745:  On MAX train into town.  Zone out trying to doze but I’m too wired from lack of sleep.  It’s a weird dichotomy, I sleep and feel good when I wake, but the moment I stop doing stuff, the utter exhaustion hits for a moment.

1815:  At work and change into scrubs.  Read the census board as I walk past toward the break room.  Notice how all the day shift nurses have that haunted look of exhaustion too.  Not a good sign.

1825:  Sit down with the day charge nurse and get report on all the patients.  Procedures done today, how agitated they’ve been, who’s been unstable, what family we’re going to 86 if they don’t leave and the most important part, what the census is and how many nurses that qualifies me for.  Looks like we’re at 16 (of 22), which calls for 5 including myself, I have one nurse on stand-by and an ED full to capacity.  One patient is on the way from ED and hasn’t arrived, 2 just rolled in at 1800.

1835:  Draw up the assignments for the night, trying to balance admits with heavy patients and how far they have to walk.  It’s not easy and somedays I feel like I’m not even close to being fair.  Tonight is one of those.  I briefly look at my patients.  First is 80 y/o male s/p colonoscopy, history of colon cancer and severe O2 dependent COPD.  The other is a 35 y/o male in with extensive bilateral PEs and a whopping dose of anxiety.  Today he had went to the cafeteria and nearly passed outin the stairwell, had a Code Green called (which usually is for visitors, but hey, whatever) and was getting extensively worked up.

1850:  Grab an extra locator for our resource nurse, make copies, collect the report sheets and head for the break room.  There I divy up the report sheets and make small talk with the nurses as they come it.  We’re out by 1905, which is near record time these days, but I’ve got a good crew tonight.

1910-2045:  See my patients, do vitals, assessments, help the echo tech with a bubble study to see if my PE guy has a PFO (never done that before, it is way cool!).  Update the census board, attempt to chart while fielding phone calls from our staffing office and the nursing supervisor.  The ED still looks packed.

2100:  Bed rounds, where all the charge nurses get together with the nursing supe to determine bed availability.  I come to hear if I’m going to get screwed.  Luckily there are medicien beds in-house, so I’ll only be getting tele patients tonight.  It’s always nice when we’re not the dumping ground.

2115:  Sling meds and tuck my peeps in for the night.  One of the guys on the floor on a lidocaine has flipped into rapid AFib while I was gone, even with a heart rate of 150 he, “feels fine!”  For the next 2 hours I help the nurse give amiodarone, diltiazem, PO metoprolol, but nothing seems to do the trick, only thing that happens is that his pressures start to drift.  I field the normal slew of questions, which doc to call, should I call, would you hold this medication and act a sounding board for my fellow nurses.

2330:  Get hit with 2 admits right in a row.  One’s mine for the moment and in a brief moment of calm, I manage to call the wife to wish her a good night.  Call staffing for my extra nurse, but find out she won’t be here for at least an hour.  Settle my new lady in, do the assessment, medication reconcilliation, admit history, then go to enter orders on her and the other admit, for I am the secretary at night.  Take a moment to pee.  Look over daily charges before I hand them over to the tele tech for entry.

0030:  Relieve  tele tech for his lunch.  Continue charting on all three of my peeps, get 2 new charts set up for 2 new patients waiting for our services in the ED.

0045:  Give report to stand-by nurse and shuffle assignments to make sure she doesn’t get only admits.

0100-0400: 4 more admits roll in.  In between patients and calls to the docs, I get my MARs signed, get my 24-hour chart checks done and finish off my charge nurse paperwork, all while eating my lunch.  Staffing calls for the census at 0400 and for confirmation of the names for the oncoming staff.    Do vitals and assessments again on my peeps.  Sit and chart on them while the tele tech goes and posts the shift’s strips in all the charts.  When I’m done I print out the census sheet that the charges use for report and start getting general report from the nurses.  It can be tedious, but it’s saved my tail a couple of times.  Luckily tonight the other problem children have been self-limited.  A couple of boluses here, maybe a little IV metoprolol,  some Ativan and a little Haldol for the crazies.  Not mention the boosts, the shifts, the help with clean-ups, nor wrangling the little confused gal who had managed to wrap herself up in the IV tubing of her diltiazem drip to the commode and back to bed without losing the site, no mean feat that!

0600:  Call staffing for the name of the extra nurse that we called for.  Find out they’re canceling one of ours, and giving us 2 resource nurses.  See the day charge walk by.

0630:  Give report, mention that we have multiple drips, a couple fo crazies, several discharges, 3 stress tests and a possible angio today.  But hey, we’re full and that means we get to work!

0700:  Act like ahuman Pez dipenser giving out Protonix and Levothyroxine.  Give report to the smae nurses I got report from thankfully.  It goes like this:

Them: “Any changes?”

Me:  “Nope.”

Them:  “OK, have a nice weekend!”

0730:  Outside to the bike cage and starting the ride home.

0820:  Get home, grab a snack, shower, watch a little morning TV.

0900:  Crash.  Thank God it’s Friday!

Writing it out doesn’t seem so bad, but it’s the intangibles that kill you.  The questions, the assists, the coordination with other departments and hospitals.  Not only am I a nurse, I’m a supervisor, an air traffic controller, a spare set of hands, a secretary, answerer of call lights, and a tele tech.  It wears you out.

Neurosurgical Set From Early 19th Century | bored-bored.com

Neurosurgical Set From Early 19th Century | bored-bored.com.

Too cool.  Glad we’ve moved beyond this, kind of.  What passed for medicine in the 19th century really seemd to be more like butchery and until the realization of germ theory and infection control, odds were pretty grim.  Not to mention lack of anesthesia!

Anniversary

Not a blog one, a job one or the date of my last shower.  Something a little more important.  Seven years ago today, my wife and I got married.

It’s been 7 years of ups and downs.  We’ve had good times, really good times and a couple of times where we weren’t sure if we were going to make it out in one piece, but we always have.  She’s my rock, my muse, the one who encourages me to be me, and who knocks me down when I get too full of myself.  She truly is best thing to ever happen to me.  Happy anniversary babe!

Dedication

A couple of nights ago we admitted one of our fine upstanding citizens after a fall on the ice.  He admitted to drinking 2 24oz.  beers to fortify himself for the trek to the local corner store to replenish his supplies while there was a lull between the snow and ice.  On admit to the ED he was lethargic, but woke on command and talked, albeit with slurred speech.  Not apparently that drunk and considering the large lump and laceration on his forehead, maybe he was still a little dazed.

They did the standard work-up as the sutured (poorly..) his laceration, including labs and a head CT.  The CT was negative for any acute process, but did show some atrophy.  Labs with one exception were relatively normal, kind of.

Any guesses what his ETOH level was?

A.  >10
B. 223
C.  499
D.  156

Not to mention issues with his ETOH level, he also had end-stage liver disease, status-post TIPS with esophageal varices and a history of seizure disorder.  Not exactly the most well-kempt of individuals mind you.  You could smell him in the hallway and he was far too lethargic to have him shower.  But back to his level.

If you guessed C., you would be correct.  Yep, 499.  Based on an online calculator, he would have had to drink 15 12oz. malt liquors in 1 hour to get a level that high.  2 big beers my ass.  He was dedicated.  Dedicated to destroying his young life.  And that was the kicker, he was only 38.  It’s sad and sick all at the same time.  The worst was that he had been doing this for many years to achieve the level of liver damage he was experiencing.  Unfortunately it seemed like the wasn’t going to stop and that the social safety nets in-place were either burned away or had completely failed.  And no matter what we as health care professionals did, he had continued to do this for years and probably wouldn’t stop until he ended up dead.  Which maybe was his ulterior motive in it all.  Now, when I crack open a beer I think about this case and realize how lucky I am.

Into the Mystic

For the sake of protection, we’ll call him Bill.  Bill was dying.  Bill’s family knew it.  The once vibrant, ox-like provider was laying in a hospital bed.  And not doing well.  The man who had endured everything from a impaling himself on a ladder as a volunteer fireman to being sprayed with boiling bleach in an industrial accident to living with a progressive neurological condition, an almost pseudo-Parkinsonian ailment, that sapped his strength and ability to do things for himself couldn’t even turn over.  It seemed like he could not endure much longer.  What had started as an altered mental status brought on by a raging UTI was turning him increasingly septic.  That was how I got him the first night.

The day nurse reported that she had fought with his o2 saturations all day, finally resorting to a non-rebreather mask, cranked up to 12lpm that was barely keeping his sats above 90%.  Not to mention he was tachypneic and febrile.  A little tachycardic, but his blood pressures were holding well.  But he had been basically unresponsive since about 1400.  She had watched him slide and felt like she hadn’t been able to do anything about it.

I pulled up his labs.  It didn’t look good.  BUN and creatinine were rising, LFTs were going up, urine output was OK, but his ABG sucked.  Acidotic, but he was trying to compensate.  What he really needed was a tube and a ventilator.  But as a DNR that was not in his future.  I saved Bill until last on my first rounds of the evening, just knowing I would be spending a little extra time.  Not so much with him, but with family.

His wife sat there at the bedside looking tired.  I introduced myself and explained what I was going to be doing for Bill that night.  She introduced herself as Betti, Bill’s wife of nearly 55 years, who had up until the last 6 months been his sole caregiver at home.  Now Bill was not a small gent.  Well over 6 foot, he would have hung off the bed if there wasn’t a foot board and well over 250lbs.  Betti was a small lady, but she had wrangled him everyday until his condition deteriorated to the point where he could no longer transfer himself.  The wear shown on her face, she had been through the wringer.  We talked as I went about taking vitals and getting stuff sorted to where I was comfortable.  I stopped thought and asked, “I know he is a DNR, but I wanted to make sure that was correct.  It is right?”  The last thing I wanted was to have people changing their minds in the middle of a situation.

She responded, “Oh yes, last thing Bill would have wanted was life with a tube down his throat.  And we all have talked about it.  The children are all agree, these are his wishes.”

We continued to talk, about the prognosis the docs had given her, the treatments we could do and the fact I was going to try to make him as comfortable as I could.  You could see the weight lift off of her shoulders, no longer having to do it all herself.  She told me how they had been sweethearts, no one had believed in them, yet here they were, together still.  She spent the night resting on a cot at his bedside.  I kept her supplied with snacks and hot chocolate and a friendly ear.  The running refrain though was, “Yeah, I’ve seen worse, but I’ve also seen far better go quicker than anyone thought.  The last thing I want to do is give false hope.  He’s one sick guy, but we’ll keep at it, OK?”

Through the night Bill didn’t get worse, but he didn’t get better.  He was still running temperatures in the 39C range and nothing would touch it,  Tylenol?  For about an hour.  Ice packs?  Nada.  I think we would have burned out an Arctic Sun machine with him.  All the time his respirations were running 35-40 a minute.  He was blowing off CO2, but the wear was telling.  Every now and then when I talked to Bill he would open his eyes briefly, almost as if to say he was still there, or that maybe he recognized my voice, or thought I was someone else.  I always let him know what was going on, even if he was out of it, he needed to know I felt.  And so it went that night.

I gave report and went home.  When I got back, things had not changed much.  But I felt something in me.  Call it the power of the spirit, or the guidance of a higher power, but I knew I needed to get Bill ready.  Betti, who had stayed all day decided to go home.  In fact I encouraged it.  I told her, “You need to take care of yourself too y’know.”  She nodded wanly, tired.  The weight had been put back on her over the course of the day.  A family friend offered to stay the night, to which I added, “Should anything change, we’ll call, ok?”

I felt helpless though.  There was nothing I could do to stop the inevitable.  I knew it, the inexorable slide had commenced.  No amount of antibiotics I could give would change it, no treatments, therapies or medical miracles could stop the process.  Bill and his family had made their choice.  In my head I commended them for their strength.  Too often, the resolve changes.  While a loved one sits at the door, they decide to throw the weight of modern medicine against Time.  Time always wins though.  But not Bill and his family.  They knew he wasn’t going to be here much longer.  While I couldn’t facilitate the “fixing” of him, I could give him every ounce of comfort I could.

Somewhere along the way I got bit by the bug to give Bill a bath and a shave.  I knew family would be there the next day and I wanted Bill to look good for them.  I can’t explain the why of it, just that I knew it was something I had to do.  Getting him ready for a trip.

So we did just that.  Got him cleaned up right good.  I even took the time to shave him, something I hadn’t done since school. He was fluffed and buffed, ready for the day.

As I left at the end of my shift, the friend pulled me aside and said to me, “Thanks for doing that, especially before his son got there last night.  I understand why Betti was glad you were here tonight.”

That made it all worth it.

Now, I kind of alluded to above, but I’m not particularly religious.  I believe in God and that mankind has an innate need to fulfill the expression of the spirit and that takes many forms.  But that night, I felt something.  Maybe it was the connection to the family.  Maybe it was the compassionate nurse in me.  Maybe it was born of exhaustion and doing what I did gave me a way to “neglect” my other patients for awhile.  I went home feeling better than I had in weeks.  I felt in some small way I had touched Bill and Betti’s lives and they knew it it and responded in kind.  Maybe it was something spiritual working through me.  I don’t know, but whatever the case was, I’m glad I got to experience it.

Bill departed on his trip later that morning, surrounded by his family, in peace. and comfort.

It’s Done…Kind Of

The move.  Finished.  Next time, please remind me to not move out of a 2nd floor apartment into a 3-story townhouse.  My calves still ache, not to mention my back and hips.  Oh yeah, also picked up a nasty head cold in the process.  Not a good time.

But now my body doesn’t hurt so bad and I’m not horking up green/yellow batches of lung butter.  Now it is time to unpack.  I might survive.

At least we absolutely love the place!

Goin’ Dark

Not exactly what it may sound like.  I’m moving this weekend…it’s gonna’ suck.  If I even get the computer in the new house by Monday I’ll be surprised, it’s going to be that bad.  Doesn’t help that the cable company isn’t going to come until Monday as well.  At least we’ll have cable in time to watch Heroes on Monday night.

Have a great weekend!