Seeker vs. Wanderer

I knew from the moment I stepped on the floor and saw him glowering at every person in scrubs who happened to walk by, that he was on my assignment for the night. I just caught that vibe. Sure enough, along with with my Spidey-sense, I got him. He stood outside the door to his room, pestering anyone who came near with the repetitive question of , “When’s the IV guy going to be here?” He would not be placated by the general knowledge that we are a large institution and that there was only 1 IV nurse. This was not to mention the fact that having badgered the day shift for the last hour, no one wanted to even attempt to try to start a line. In spite of that, he wanted his line, “Now!” His need for IV narcotics outweighed our responsibility to our patients here at shift change. He wanted it now. And he wanted us to slam it. Not push normally like we do, but slam it fast, so he could ride the rush.

I looked over my report sheet: severe triple vessel disease, scheduled for open-heart in the AM. History of traumatic brain injury, depression/psychotic episodes, mixed personality disorder, ETOH and polysubstance abuse. I shuddered at the thought of being his nurse post-surgery. There was not going to be enough narcs to throw at him to make him even the least bit happy. The surgery may fix his chest pain, but it would do nothing for his “chronic back pain” nor his near-insatiable need for prescription pain meds I found related in the tales of admissions past. No, he was a nightmare of a candidate for open heart. Thoughts of pouring tons of Oxycodone down his throat all the while pushing morphine to back it up while keeping the syringe of Narcan in my scrub top danced in my head. I shuddered again. It was not going to be pretty. Did I also mention that he had us pretty much figured out from the start and knew every way to twist us into giving him what he wanted.

He got the line. We told him that he only had X amount of narcs allowed in the current time-frame. You would have thought someone had called his mother a whore the way he exploded. Ranting and raving, starting to get a little belligerent. Back in the recesses of my mind I calmly called forth the number for Security, just in case. Lucky for me, this was transpiring while I was dealing with another patient. My charge nurse took the brunt of the abuse and did what nay good nurse does: calls the doc. Bless his soul, he got an extra one-time dose, plus a PCA. Narcosis on demand.

Deep inside however I was a little conflicted. We ended up giving him exactlywhat he wanted: access to large quantities of narcotics. Sure it shut him up for awhile, but was it the best thing to do?

Maybe. Maybe not. If nothing more, we fed the notion inside his head that given enough histrionics and emotion, he would get what he wanted. Like a petulant little child throwing a tantrum was the way to walk out of the store with a new toy.

Since he was going for open heart surgery I tried to do what teaching I could do. When you’re half gorked on pain meds, your comprehension level decreases substantially. Did any of it stick? I doubt it as I came back a little later after having gone over the incentive spirometer to see him unable to figure it out without a little extra coaching.

In spite of all of this drama, to which many is a way of life, I got him ready to go. Fluffed, buffed, cleaned and shined, ready to have his chest cracked like a fresh oyster. As he was getting ready to roll out the door he asked, “So, are they going to give me pain meds down there? Or just put me out?” Nothing had stuck except the one all overarching basic need in his mind. How ER nurses deal I can’t fathom. Right now I’m just praying that I won;t get him.

Have a safe and Happy New Year!

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Insomnia

It’s quarter to seven in the AM and I’ve slept all of about 3 hours.  I laid down to sleep and fell asleep, only to wake about 3 hours later.  I didn’t think I would have a problem flipping to day-side this time.  But I am having trouble.  I’ve been on nights schedule for 3 three weeks straight thanks to “issues” with my (read: the floor ) schedule.  Y’know, the lovely 3 on, 1 off, 1 on, 1 off, 2 on…and on, never fully able to flip into day-side, nor completely on the night-side.  Kind of in a temporal purgatory, where one is always tired, no matter what you do.

My doc (bless her) wrote Ambien for me, to help, “ease the transition.”  I felt like I wouldn’t need it tonight.  And, when I realized I did, it was far too late to take it.  I can’t be sporting and Ambien hangover for half of the day.   As is the norm this time of year there is much to do.  Presents to wrap, cookies to bake, houses to clean, in-laws to run away from and the general manic overload of the season.  I’m glad I don’t have to drive anywhere for Christmas.  For once, everyone is headed our way.  And methinks that is the root of the problem.

Honestly, I do like my in-laws.  My mother-in-law is great.  Her words of encouragement in nursing school always haunt me, “if I ever heard that you said ‘this is the CNA’s job,’ I (all $1.25, soaking wet of her) will personally kick your butt!”  Her ex-husband, my wife’s stepfather (guess that makes him my ex-stepfather-in-law?) is a whole other ballgame.  I know everything I have heard about him is tainted by the experience of those who lived through it, but I have seen his worst side on more than one occasion.  It ain’t pretty.  Like many of my difficult patients, I have learned to handle him and at times like him a little.  But having him here carrying along the tension that exists between him and the rest of the family will make life a little more difficult.

It appears that I will have to “cowboy-up” and muddle through this episode much like any other I have muddled through in the last 9 years (soon to be 10) I have been a part of the family.  And I hate to say it, but I’m almost looking forward to going back to work next week.

Besides the nagging dread of the in-laws, to top it all off, the cherry on top, I’m coming down with the “crud” as well.  Sniffling, coughing, general malaise, post-nasal drip – the works.  Yes, it going to be a Merry Christmas indeed.

Now that I’ve cast a pall on anyone reading this, let me reassure you: I have grown to love the Holidays.  After working in the airline industry, I hated the Holidays.  It was the busiest time of the year.  Now, I love it.  I will enjoy it.  Now as in “Christmas Vacation” it may take a little help from Jack Daniels, or in this case, Captain Morgan, but I will survive.  And maybe even have a little fun!

Wishing all a Merry Christmas and a Happy New Year!

Just another night.

It was just another night.  Not too out of the ordinary.  My patients were all tucked in, chart checks were done, I had even had time to go off the floor for a half hour to eat while watching Sportscenter.

Out of my 4 patients, only 2 were on telemetry therefore, only 2 required the 4am vitals.  That I figured, could wait until 4:30, maybe even 5am.  Heck, why not let them sleep a bit?  One had come in at the god-awful time of 0-dark-thirty the previous night and had unfortunately kept the other up most of the night in the ever time-consuming process of admission paperwork (even though I am a bit of a whiz at it…).

I had been keeping my eyes and ears open, slowly watching the little green squiggles of the EKG lines trace their way across the monitor, trying valiantly to stay in some semblance of wakefulness.  One of them, Mrs. S., I had been keeping a closer eye on than usual.  Nice older lady, in with pneumonia, A-Fib with RVR and ground level fall.  The pneumonia had been getting better, instead of crackles and wheezes all the way into her upper lung fields, they had retreated down to the bases, still there but not as bad as they had been.  Her A-Fib had been wrestled under control with a little help for our friends Cardizem and metoprolol, ususally she lived in the 90-110 range, give or take, even lower when she slept.  All night, she kept coughing, that pneumonia cough, it never really brings anything up, but never really goes away.  Just nagging enough to keep her partially awake.

But tonight it was her rate that was on my mind.  All night it had been creeping up, never drastically, but like the cough, just enough to keep my attention.  It was 3:30 and she was hanging out in the 140s now and had been for awhile, so I was starting to get ready for some meds.  She had just rung the bell and our oh-so enthusiastic aide went to see what she needed, (mind you, it was that kind of a night for everyone).

As she comes out she says, “Hey Wanderer, she says she’s feeling a little short of breath, not too good at all.”

“I’m on it,” was my reply.  As I’m heading into the room the “oh- shit!” alarm on the monitor starts going nuts.  “Hey Wanderer,” someone shouts from the station, “That’s your lady, she went up to like 180 and is sustaining in the 160’s!”

“Shit.”  I mutter to myself as I bust into the room like Patton himself.  She looks up at me with that worried scared face and says after she stopped coughing, “Y’know, my cough is getting worse and I don’t really feel like I’m getting a good breath.  And my heart feels like it’s beating really fast.”  I can hear her lungs from the foot of the bed, they sounded like Sponge Bob could live inside the ocean that was filling her pulmonary system.

Cool as a cucumber, but starting to shake just a little, I said, “Well let’s check this out,” and start hooking her up to the in-room monitor.  The monitor starts bing-ing the “oh shit!” alarm again: rate in the 160’s.  I reach down feel her radial pulse, yep, feels about right.  I take a listen with my stethoscope.  Yep, wet, wet, wet breath sounds all the way up, from the bases to the tops.   And her cough had turned from non-productive to a more milky, frothy kind of gunk.  “Not good Wanderer,” I said in my head, “I need to get the rate down.”  So I sit her up in bed, turn the 02 up a little more and have her take some nice slow breaths and tell her, “I’m going to go grab some medicine to slow your heart a little OK?”  Hoping that the adrenaline now pumping full-bore doesn’t make my voice quaver at all.  She nods.  “I’ll be back in a moment, call me if it gets worse.”

Out to the nurses station, I grabbed the phone to page the intern.  With the page on the way I went into the med room to grab the metoprolol I had intended to grab before the aide grabbed me.  Pull the med out of the Pyxis, override for Lasix and my pager goes off.  “413”  code for phone call.  Pop out of he room, “It’s Dr. Night-Intern on A” someone says.  I pick it up, “Dr. Night-Intern, Sir?  You guys are still following Mrs. S, right? came in with pneumonia and A-fib with RVR?”

“Ahh…” I hear pages rustling oint he background, “Oh,yeah,we still are…”

I cut him off, “I think she’s trying to flash over on me, she has frothy sputum, lungs sound wetter than they did at start of shift and her rate’s been sustaining above 160 and has gone as high as at least 180.  I have metoprolol PRN, but can I get an order for some Lasix to help get the fluid off?”

“Ummm, uhhh,” I’m watching the monitor, rate is 170 now, “Well, what’s her renal function like?” he comes back with.

“BUN and Creat are WNL, K this AM was 4.3, she got 40 mg of IV Lasix this morning.” hoping he hears the urgency in my voice.  I really don’t want to have to call a rapid response now.

“OK, did the Lasix work this morning?”  I smack my hand against my head, time is not on my side right now I’m thinking, “Uh yeah, sounds like it worked great, she put out approximately 1500ml for day shift today.”

“OK, go ahead and give 40mg IV times 1, now…” he says.

I cut him off, “OK, what’s your P#?”

“Oh, does she have labs this morning?” he asks.

“Nope, no labs, want one?”

“Yeah, grab a comp and a mag this AM.”  he comes back with, “P# is 1234567”

“OK, thanks Dr. Night Intern, I’ll call ya’ if you I need anything else.”

I look, it has taken all of 2 minutes, tops, but felt like a near eternity.  I had already pulled the Lasix up after he had said “OK” (and who said we shouldn’t multi-task?).  I looked up at the monitor as I headed back towards the room, looked like 160’s still, bumping to 170.

“OK Mrs. S, I have some medication here for you, gonna’ put it through your IV , OK?”  She nods as we go through the JCAHO rigamarole of identification – name, DOB, cat’s name, mother’s maiden name and shoe size in Europena sizing – to determine that it really is Mrs. S.  I grab a quick BP as I start to give the metoprolol.  When the machine stops cycling it shows 140’s over 100’s.  “Well, that ain’t good” I think to myself.  I’m a little calmer now, but still riding the crest of the adrenaline surge.  I finish pushing the metoprolol, as the machine cycles again, now we’re down to 140’s over 80’s, not great but better.  Heart rate is already starting to drop, now sustaining in the 140’s.  I push the Lasix and say, “I apologize to do this to you at this time of the morning, but it will help get some of that fluid off your lungs.”

She says, “It’s OK, it’s what needed to be done.”

I look at the rate, now we’re into the 120’s, respirations are down to about 18-20 and BP is running near her baseline of 120’s over 60’s.  She even looks better already, that worried face is gone, in it’s place relief.  “I’m just going to hang out here for a couple of minutes OK?  Just to make sure we’re doing better.”

She looks up and says, “It’s OK, I’m already feeling better now.  I feel like I can breathe a little better.  I’m glad you were here to help me.”

“I’m glad I was too.”  As I said that, I was thinking to myself that if I was as good of a nurse as you think I am, you wouldn’t have been in this situation.  It’s really my fault that this happened at all, I wish I had the balls to say.
At midnight she had PO metoprolol due, but with holding parameters, HR <60, SBP <90.  Being the ever-prudent nurse I am, I checked both prior to giving the meds.  HR had been 110’s, but SBP was 88, so in concurrence with the parameters, I held it.  Now, I know that there is no way to prove that was the precipitating event, but I felt deep down that maybe it had something to do with it.  I talked it over with my colleagues and they agreed: it was a crap shoot.  The pevious night her SBP had been fine but the dose dropped her 10 points and she had felt a little goofy and wobbly when she was standing, so I didn’t want to repeat that, but I wavered knowing that the primary reason for giving her the med was rate-control.  In the end I didn’t give it.  That’s why I kept my eye on the monitor all night long.  That’s why I was coiled and primed, ready to run in, because I had that feeling in my gut that something might be afoot.  It was a heck of way to re-learn a lesson, or at least give me bigger pause the next time to reconsider the meds I am giving.  It taught me a lot about nursing judgment.  We’re entrusted to make decisions that have life-changing effects on our patients and even when we think we’re making the right choice, we’re not always.  I know that judgment gets better with experience but sometimes you get burned. The good thing though,  was that it was caught early and treated before it got worse. Besides that, I realized that if this had happened less than 6 months ago, I would have called rapid response.  Granted, I would not have been wrong to do so now, but I felt comfortable in not calling the team and managing it myself, knowing I had backup a mere phone call away.

As I finished charting the episode and my adrenaline started to fade, the monitor tech came back to post the strips and asked, “Did you see how high your lady’s rate went?”

“No, I hadn’t.  How fast?”

“It topped out at 201 and spent a lot of time in the 180’s.  Is she OK now?”

“Holy crap, any wonder why she didn’t feel that great!  She’s doin’ OK now.  Nothing a little metoprolol and Lasix couldn’t fix!”  I said with a grin and went on my way.

And the night continued.  Just like any other night on the floor.

Diagnostic Uses of a Hershey Bar

As related to me by the nursing supervisor the other night…

Patient presents to the ED with a chief complain of dyspnea.  The doc comes in and starts to look him over.  On exam he notices a large brownish stain on the man’s forehead.  Pointing to it he asks, “What’s this from?”

“Well you see doc, I was feelin’ like I might have ah feevah’ but Ah don’t have no thermometer.  But my cousin said she had chocolate bar though.  We figured if we put that up to my head there, it would tell me if Ah had a feevah’.”

Now I’m no rocket scientist, but how does one determine body temp from a Hershey bar?  Is how quickly it melts?  But wait it gets better…

“So besides the fever, you say you’re pretty short of breath.”  The ED doc continues, noticing that the patient is breathing about 22-24a minute, labored, sats in the toilet.

“Yeah.  I was having a little problem breathing at home too. I was watching the tee-vee and saw that the mountain climbers were smoking because they were having a hard time breathing.  So I sent my cousin out to get me a pack of smokes.  Thought it would make me feel better”

“Do you normally smoke?” asked the doc.

“Naw, but since I saw it on the tee-vee,  thought it might work.  So I had a couple.  But it didn’t work so good, so I came heah.”

I’m sitting here wondering, maybe we could get Materials to stock Hershey bars instead of thermometers and smokes instead of non-rebreather masks.  It works on the tee-vee don’t it?

Bits and Pieces

I haven’t been in the mood to do serious medical-type blogging. There are stories to tell, but I can’t find the motivation to share. Maybe it’s a bit of blogger burnout. It could be that I’ve been off for 7 days now and thoughts of nursing about as far from my mind as you can get right now. Instead I’ve been consumed with reading, catching up on TV shows and blogs, cycling, enduring PT and trying to help get the house together in time for the Holidays.

I spent some time downtown with my camera the other day, and in spite of the 21 degree temps (with wind chill), managed to get some nice shots and generally enjoyed myself. I tapped that side of creativity instead of writing. Whatever it takes right?

I added some updates. Up above the header are 2 new pages, Pics and Weekly Playlist. Pretty self-explanatory right?

I know I’ll get motivated again, there are a couple of god ones in the pipe, it’s just a matter of putting pen to paper, so to speak.

Enjoy this old commercial in the meantime: (via Commute By Bike)

It’s just a shame it wasn’t for better beer…although, it could have been worse.