Forget much?

I have to admit, if I had to choose between an asshole drunk and a pleasantly confused elder, it’s a no-brainer.  Yeah, they may be forgetful, even a bit daffy, but those pleasantly confused LOLs crack me up.  They’re a hoot to work with, and like kids, they say the darndest things…

The other night a colleague of mine had taken one of our LOLs to the bathroom.  They definitely were in the pleasantly confused arena, but like many folks with dementia had moments of true lucidity that shock you.  He gets her to the bathroom and reminds her to pull the call cord when she was ready to head back to bed.  She looks him dead in the eye and says, “I’m going to forget to do that, you know.”

Sure enough, she did.

No, we need it now.

Somedays our hospital staff just baffles me.  Somedays they are über-ready to get something done, like the CT tech who calls 30 seconds after you put the order for a CT in.  Other days you call phlebotomy and three hours later they show up to draw a “now” lab.  There’s no consistency.  And when you need something like blood, it’s usually not just something that you can be “meh” about.  Case in point happened a couple of weeks ago.

We had a patient who needed blood.  Badly.  Unfortunately due to their specific disease and numerous antibodies, they needed special blood.  The Red Cross had to fly it in.  Yes, fly it to us and we’re fairly good-sized city.  It’s not like we’re in the middle of podunk backwoods-land.  The blood bank calls us at 1am and says the blood has arrived and we figure we’ll be getting a call soon that it will be ready.  2am, nothing.  3am, nothing.  The house doc comes up asking if the blood has started, he wants it done now.

So we call blood bank.

“Calling about the blood for us up here on 5.  Is it ready yet?”  asks the nurse.

“No, we’re having a problem with the computer and can’t get it ready.” replies blood bank.

“No, we really need it soon.  It’s kind of important.”  replies the nurse.

“Well, you see there’s a probelm with the computer generated tag and I can’t do anything about it.  Only my supervisor can has the right access…”  says blood bank.

“And when are they coming?”  angrily asks the nurse.

“Uh, I haven’t called them yet.  Don’t really want to wake them up, it’s 3am.”  they say.

“Maybe you don’t get it.”  says the nurse.  “My patient’s H/H has dropped to 5.0/16.3 in the last 4 hours that you’ve been stalling on getting the blood to us.  You need to call them.”

“Let me make a call.”  they reply.

30 minutes go by.  The house doc comes by again, still wondering if we’ve started, which we haven’t.  And then comes the cool part.  He calls them.

“Look, I don’t care if the supervisor has to override this or that.  My patient needs blood.  If they haven’t arrived in 10 minutes, I’ll come down there and sign the blood out myself, to hell with your computers.”

Guess  what?  The blood was ready in 7 minutes.  Sometimes having an MD to throw their weight around is a good thing!

A Happy Hospitalist: What Happened To The Nursing Profession?

A Happy Hospitalist: What Happened To The Nursing Profession?

….I was going to write a bitter polemic about this, but realized that it would just fuel Happy’s ego.  It’s bad enough that I’m linking to it, but I had to say something about it.  So here goes:

1.  More often than not as nurses, we’re not allowed to exercise our critical thinking and judgment thanks to rules, regulations and policies.  Even when we know that it is not necessary to call (thanks to our experience, training and critical thinking), we still have to call, or if nothing more, document why we didn’t.

2.  Some nurses are better/more experienced/better educated/have more common sense than others.  Same goes for doctors.  ‘Nuff said.

3.  We’re not always sure the doctors are aware of the situation (many times they aren’t…) so we call to inform them of it.

4.  Us night shift nurses really love nothing more than to call up a sleeping hospitalist at 3am to report a critical value (that really isn’t, see point #1).  It’s almost as much fun as having to call a cardiologist at that un-godly hour.

Just my view.

That Team Spirit

For the most part my floor has been a cohesive team.  There was a sense of togetherness and mutual support that  was very comforting.  You knew, based on who was on, if someone had your back when the shit hit the fan.  While there were a few times where that was suspect, for the most part you knew you had support.  Usually there was someone around to ask questions of, if nothing more, bounce and idea at, just to see if you were thinking correctly or if you were way off base.  It was a family of sorts, dysfunctional at times, but a family.

We underwent a split this last summer, with some core staff on each new unit and the rest of us floating between the two units based on census and need.  Because of this, there began to be fissures in the feeling of security.  While you knew for the most part that if really needed, there was someone to back you, but that feeling of family seemed to be fading.  Attitudes emerged which further added to the division.  On the less acute unit, an influx of new grads made that feeling of being alone even worse.  Not only did you have your issues, but if you were a “seasoned” nurse, you inherited their issues as well.  There have been nights where it was me and one other seasoned nurse and the other 4 or 5 were new grads. And it wasn’t an issue of them being bad nurses, but it was the lack of experience, that acquired knowledge and comfort zone that comes with working with the kinds of folks we do for them to be self-sufficient.  Many nights I felt like the Oracle at Delphi, answering questions non-stop thru the night.

That sense of team was pretty loose.  We all worked together, but it wasn’t as tight as it may have been before.  In the last month however our manager decided to make a permanent staff split.  The floaters would be gone and each unit would have a set core staff.  There might be a little floating, if needed, but the staff would be set.  We knew it was coming, it was only a matter of time.  It had to happen to allow a set staff to develop that necessary bond of a team.  If you constantly have different people flitting in and out, getting to know your fellows, their strengths and weaknesses was difficult.  But when you start working with the same folks night after night those imperceptible bonds begin to emerge.

A new energy has begun to settle onto the unit.  That mild sense of uneasiness and doubt is beginning to fade as the staff are slowly getting to know each other.  It’s nothing that you can point your finger at, but a general sense of a team starting to emerge.  When things start to go south people are stepping in to ask if the nurse needs help, offering to do what is needed.  When we have an admit dropping into our laps at 0705, they get 2 nurses working to get them settled in, without the admitting nurse asking.  When I was trying to admit a patient at 0430, the busiest time for me as a charge nurse, one jumped in to finish a long and complex medication reconciliation, despite my protestations.  It’s starting to gel and form into a cohesive group of professionals.  Sure I get asked questions non-stop, but it becoming more of a “Am I thinking about this correctly?” more than the “Uh…what do I need to do now?”

And I know I’m not crazy, others see it too.  Several of us went out for breakfast the other morning a we all commented on this fact, that it’s starting to feel like a team.  I wish I had a company card so I could have expensed the breakfast to the unit under “team building”, but alas that doen’t happen.  But becoming a team is.

Sleep. Wonderful Sleep.

A word of warning to those about to be admitted to the hospital:  we will not let you sleep.  At least we will not let you sleep much.  A couple of weeks ago I was working on our step-down unit taking care of a couple of folks who were convalescing from open heart surgery.  You would think that sleep would be an essential part of the treatment.  Sleep is the restorative, the healer and the way we escape.  But if you have had open heart surgery it is not going to happen.

My two patients the other night got at most, 2 hours of sleep at a time.  More like little naps than actual restful sleep.  Here’s how it breaks down:  2000, vitals and assessments, 2200, CBGs and meds, 2400, vitals and assessments again, 0200, CBGs, 0400, vitals, assessments and blood draw if they have a central line, 0500, lab draws, and then they’re up in the chair washing up prior to breakfast.  Any wonder that we get so often in report that, “Well, they kind of slept alot today.”

Really?  It wouldn’t have anything to do with the fact we don;t let them sleep at night, would it?  Now I understand that most of this is warranted, if at least nothing more than for us to stay busy.  Our surgeons actually write for vitals QID, but due to the way our protocols are written, if they are in the step-down unit, they get q4 hour vitals and assessments.  There is no real flexibility…unless you actually exercise your nursing judgement and decide not to do one set of vitals or such.  But the urge to cover ones ass, especially when you’re out of practice with open heart patients, is strong.  While we have the autonomy to make our own decisions, it sometimes feels like we are not encouraged to do so.  THere have bentimes where I look at my patient and go, “Hmmm.  They look pretty stable, I think I’ll skip the four-o’clock rounds.”  Other times, I’m looking in every 20 minutes.  It goes to the core of being a nurse, the ability to make an informed decision to best support your patients’ healing.

Unfortunately trying to change these protocols is a near-impossible task.  Read: it will never get done.  So in the meantime we’ll be waking you up every 2 hours, or so.

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.

Ummm…carcinogenic

After reading that one day I will die a slow horrible death due to cancer what did I do?

Went home, had an unfiltered smoke, ate a near-raw steak, walked outside in the blazing midday sun without sunscreen and took a shower in benzene.

Actually, I ate at McDonald’s and slept for 2 hours.  Something tells me option A would have been better.