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.

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Ratings, the Whole Story?

Cued in by a story on CNN.com to HealthGrades.com I decided to venture in a look around.  I mean why not look up your institution to see how you rate?  I picked bypass surgery and angioplasty as these are things I’m familiar with.  It wasn’t pretty.

I don’t know their methodology, nor did I take the time to sort through it, but we didn’t stack up so well. Comapred to the rest of the hospitals in the area we really sucked.  Our scores for in-hospital mortality for CABG and angio was 1-star and 3-star respectively, poor and as expected.  For 180 days out we were as expected and poor respectively.  Not exactly stellar.  Not horrible, but it wasn’t what I thought.  I started to doubt myself, thinking that, “yeah, I guess we’re not as good as I thought.”  Then I realized:  it’s only numbers.

Here’s what I mean.  These are just scores based on statistics and numbers.  Surface level, no drill down or adjustments for severity, acuity or complexity.  Why?  I think that no one outside the medical establishment cares much for that.  The public wants to know the simple straight forward numbers.  1-5 star.  Easy, simple and uncomplicated.  I may be wrong and underestimating the American public, but I’m not too sure.

Why, I asked myself were our ratings so low?  Complexity.  We take complex folks, especially to surgery.  It may not be the wisest choice, but someone has to do that.  Our bypasses are not simple, far from it.  Last week I took care of a 4-vessel CABG with aortic root replacement and a 5-vessel CABG with intraoperative arrest and re-bleed requiring re-opening of the chest off-pump bypass followed by closure.  Our CABG patients are sicker than most.  Diabetes, COPD, sarcoidosis, thrombophilias, smokers, alcoholics, drug addicts, end-stage renal disease and the morbidly obese.  We take them when no one else seems to.  The worst I saw was a morbidly obese patient, end-stage renal disease, had a 4-vessel bypass, replaced the aortic and mitral valve and the ascending aorta.  I sat in on the surgery for over 10 hours and they were still going strong when I left.   It’s not that our surgeons are inept, nurses uncaring and unprofessional and our units unkempt and filthy, it’s that our people are sick, with a capital “F”.

I would venture to say though, that if you have a complex situation and needed bypass surgery or a valve, there’s not a better place to be.  If you want a minimally invasive mitral or aortic valve replacement, there’s not a better place to be.  It’s just that our reporting and the pure numbers suck.

A couple of days after I looked up the numbers and thought this all through two patients reinforced my belief in my institution.  The first was the family of a patient transferred from another hospital with a stroke.  They had previously had their CABG in our facility, but had been taken by EMS to the other facility with their stroke. Being a curious sort, I asked why they were here.  The daughter said this to me, “Well we had such a great experience with you guys when we were here for bypass so we thought it would be good to come back.  I asked my brother-in-law who works up at the large educational institution up the hill and he said that even with his loyalty to the educational institution he would take them to Good Shep.”

It blew me away.  Even someone else was saying we were good.

The other was a CABG patient I was taking care who told he this: “My boss looked up and down the West Coast and he told me that for the surgery I was having, it was between you guys and a place San Fran.  I just knew you guys were the best.  Y’all have been great.  No bullshit, just straight shooters everyone.  From the doc to the nurses.  It’s been real good.  Y’all have changed my life.”

To me that’s better than any rating, statistic or number in the world.

Young MIs

How I survived a heart attack at age 43 – CNN.com

Seen it.  Took care of a patient who had their CABG at 49.  Scary.  Sounds like familial hypercholestemia to me.  This blew my mind:

The oddest thing about the angioplasty was that for six hours they told me not to move my foot, and I didn’t know why.

I know whenI’m taking care of post-angio patients, the whole, “you had a large hole in your femoral artery” is the first thing I bring up when doing post-angio instruction.

How I Spent the 4th.

Getting the snot beat out of me… I don’t know if the guy who gave me this as a prize was commenting on my masculinity (or lack thereof…) or that maybe, he instinctively knew I was a nurse and knew the true roots of “Girl Power!” My second thought was, “Is it that obvious I work with all women?” He must have been a psychic as well as a carnie.

The coolest thing though happened to me at work this morning. I always feel weird around those who I’ve performed CPR on – those that have survived. So imagine my surprise the other night when our Code from the Night of Many Codes came back to the floor. As committed team member I went in with another nurse to get a patient cleaned up for the day. It was a bit odd, as laying here was a patient who last time I had seen them was quite nearly dead, if not truly dead. That night his pressures had been dropping all night and just didn’t look good. Respiratory status diminishing, really working hard. I pop in to see if the the nurse needs anything and end up finding the blood pressure as 60 palp. Things progress to a full blown Code. Luckily, being a fresh post-op heart, the wires were still in place. But until we got them hooked up to the temporary pacer, we had to do CPR. On a fresh heart. At least we didn’t have to worry about breaking ribs. The strange thing was the supple compliance of the sternum being held together by surgical steel wires. CPR was downright easy on this patient.

Now imagine my surprise when they’re pretty much neurologically intact, granted they stayed a month in the Unit and their kidneys went to hell, but they’re alive and talking to us. As we go about the tasks of turning, moving, sliding, rearranging linens, getting a new sling positioned (did I mention they can’t help much with care..) He says, “Hey,watch out for my chest!” pointing at their sternum. “It still hurts, had a lot of trauma to it.”

The other nurse looked over at me and we both grinned and chuckled. He continued, “What’s so funny?”

“Nothing,” I say, “We know you’ve had some trauma there. And let me just say I’m sorry about that.”

I didn’t fill him in on the fact I had been pumping on his chest 3 weeks ago or anything like that. Just took the opportunity to say sorry!

Me. And my big mouth.

I did something stupid the other week. Something I regretted doing. It wasn’t dangerous, didn’t put any patients in peril, cause mass calamity on a national scale, nor promise unlimited health-care for all, nor deny inappropriate relations with a well-connected lobbyist, or drive my car into a train tunnel, but it was just stupid, and I paid for it.

About a week ago a resource nurse who comes to our floor a lot and I were talking and commiserating on the fact she had a trio of poopers. “All I’m doing tonight is cleaning up poop. Even though one has a flexi-seal, it’s still leaking out.” she said.

“Well at least you were prepared for it…your undershirt is kind of c-diffy colored…” I came back with.

“Yeah thanks, I know Captain Obvious.” she said, “It wasn’t the best choice. I should’ve known with this floor!”

And then I said it. The phrase that would doom me into poop-servitude: “Y’know, I haven’t had a night like that in a long time.” Stupid. Stupid. Stupid. It’s like saying “q—–” on a full-moon night, or “she’s finally asleep” about the demented old lady who had been trying to climb out of bed all night. In the grand karmic wheel of nursing, I just steeped in it.

So I show up Tuesday night, flushed with excitement from a nice ride into work, changed and ready to rock. And I start looking at my assignment.

#1: “bradycardia, s/p CV“. OK, he’s a walkie-talkie, fine.

#2: “synope” Again, OK, she looks like a walkie-talkie.

#3: “s/p CABG with AVR, post-op delirium and colitis.” Uh-oh…look a little further down the sheet on him, “mulitple loose stools, (c-diff – !)”
“Yep, could be fun but at least he doesn’t have c-dif,” I thought. Then I read a bit further, “Neuro: A & O x1-2, weak, 2+ assist up, left-sided weakness (new?), strict bedrest.” Now things were getting interesting.

#4: “sepsis, due to C-DIFF.” Yes, here it was the karmic retribution for the words so casually spoken the week before. “Neuro: confused and forgetful, A & O x1-2; Activity: up with 2+ max assist. GI/GU: foley, incont. of stool, 1 loose/mucoid stool.” That’s all of the report I needed. It was going to be one of those nights. Karmic payback.

The day nurse then told me, “Yeah, I d/c’d the flexi-seal yesterday.” I nod glumly, knowing that I would be spending quite a bit of time in the room that night.

So as the night evolved, I did the nursing thing. Checking briefs everytime I head into the room. 2100: still ok. 23:00: so far so good. 24:00, “awwww, hell naw”. Blow-out in #4….I felt like paging overhead, “clean-up on aisle three, clean-up on aisle three.” and clean-up we did. Nothing like a full-bed change blow-out session.

Then #3 rings, “yeah, I ate an apple, then I shit,” he says. That’s one of the things I love about old men, they’re so…well…honest. Clean him up. I’m out of the room less than 10 minutes, “Yeah,” as I answered the call-light,”I shit again.” And on, and on, and on. Cleaned him up 5 more times that night. The C-Diff lady? Nary a time after the blowout.

Fast forward to night #2. I still think I have poop on me somewhere. Even though I have new scrubs on and showered twice since being here. I can still sense it. Not really smell it, bu it more like sensing it, just out of conscious smell range, but there, like the lingering after scent of a bad bar night.

Same peeps. New issue though. Find out #3 has VRE. In his stool. That we had been cleaning for days on end. Without gowns. OK, so make that 2 peeps on contact precautions. And still pooping. Lots.

About midnight I call up Materials, “Hey, this is Wanderer up on 4. Can you send up some more of the big blue chux and another 4 or so packs of isolation gowns and a box of the peri-wipes? We’re going through them like they’re going out of style.”

And the battle continued. I think I singed off all of my olfactory nerve endings those 2 nights because I couldn’t smell anything when I go home in the morning. After I left each room, the smell no longer lingered, it’s like there was nothing for it to linger on. They were gone. Which I guess could be a good thing.

Onto Night 3.

Charge nurse (different on from the past 2 nights) hands me my assignment and says, “I took away #3 from you, it’s just not fair to have 2 isolation patients.”

“Uh. OK, I had them both last night…but I’m not going to complain.” I said. But in fact, it was worse. Instead of having 2 poopers, that I know well, and have kind of gotten used to their unique idiosyncrasies (i.e. smell), I get one and a new cast of characters.

In retrospect, it was OK. She was just spreading the love. Out of the 6 nurses on my particular side of the floor, everyone had at least 1 isolation patient, most were contact, for c-diff. So we all had the love that night.

But what did I learn?

Yes, never, ever, open your big mouth. Karma’s a bitch. Even though you know you’re due, just don’t say it. Let it go. Maybe you’ll stay free a little while longer.

That shoe covers are this year’s must have accessory!

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And that I look good in yellow

Seeker vs. Wanderer: The Rematch

I knew this day would happen: he would come back to the floor. I recounted our last encounter here. And tonight he was on the census. A cold chill swept over me as I looked over that innocent piece of paper. I knew. He was part of MY assignment.

For those not into reading the back story it is thus: admitted for a CABG due to severe diffuse 3-vessel disease; history of multiple psychological issues not limited to polysubstance abuse and ETOH. Not exactly what I would call a good surgical candidate. Our first match ended in a split decision. He got some of what he wanted, I got a little of what I wanted.

Now after a lengthy stay in the Unit, punctuated by a bout of pneumonia, a PE, septic shock along with the expression of underlying psychosis and delirium as evidenced by agitation, belligerence and violence towards staff. He had spent a long time intubated, more to support him through the wonderful detox process than anything else. He had become very good friends with a variety of restraints. But no longer was he critical enough to keep in the Unit, intubated and sedated. So up to the floor he came.

I knew that right away I was going to have to set boundaries.  It was the first thing I needed to do.  So in I walked.  “Oh yeah, I remember you.” he said.  “Can I get some pain medication?”

“Not right not, I’m going to have to look and see when you’re due next.”  I responded.

“Yeah, but it’s time.  Right?” he countered with.

So I looked him in the eye and said, “Let me tell you what.  I will make sure you get what is prescribed, when it is due.  Not before.  I will do this.  Your part is this:  no comin’ out in the hall, harassing us, creating a scene any of that.  You up for this?”

“OK, but I know it’s time.” he said.

“Let me go look.”  Out in the hall I looked.  It was a long time until it was due.  And out into the hall he wandered.

“I wanted to tell you.  I was wrong.  It’s not due for another hour.  I was looking at the clock wrong” he admitted.

“Alright.  I’ll be back at  10…on the dot.”

So I kept going, working my tail off trying like mad to make sure that I was in that room when it was time. I knew that I was walking a fine line, putting my credibility on the line.  If I didn’t show, my credibility was shot, null and void.  If I came through, I could establish a level of trust that would keep him calm and make my experience a little easier.  I looked at the clock, I had fifteen minutes to give meds to another patient and be back in time to give away pain meds.  Yeah, right.

You see, if the IV was OK and not kinked, it would have worked out perfectly.  But like most things in nursing, perfect is pretty damn far away.  I spent a couple of minutes wrangling the IV, re-taping it, flushing it and ensuing it was still patent before giving out some steroids.  All of sudden my charge nurse pokes her head into the room.  “Do you have meds for Mr. S.?  He’s causing a scene in the hallway.”  Shit, I mutter to myself looking belatedly at the clock on the wall: 10:01.  He’s nothing if not punctual.

“Yep, got ’em right here,” I said hading them over to her.  I knew I was screwed, that I had lost the credibility and trust I worked to create.  A wave of anger swept over me.  Why was I so enthralled…no controlled by this?  Was it more than just self-preservation, or was it something deeper?  No matter what he thought, I was in control of the situation, I had to be.  I had set the boundaries and what I expected.  So I headed over to the room.  “Didja’ get your meds?”  I asked.

“Yeah, but they were late.” he said.

“But you got them.  I was involved, but you got taken care of.  Next dose it at 2.  I’ll be in then. Anything else you need?”  I came back with.  Nothing but sullen silence.  He refused the other evening meds, but did let me check a CBG.  Small battles add up to a larger war.

Fast forward to 2am.  In I go, give the meds and let him get back to bed.  “I’ll be back at 6.  I need to do vitals and draw labs, let me know if you need anything.”

At 6, I walk in.  Silence greets me.  “I bought your meds like I said.”   Nothing.  He just rolled over.  “You don’t want them right now?”

“No” he blubbered, “they don’t do anything anyways.  I just want to sleep.” he finished with a whimper.

“No problem.  I’m going to draw labs out of your PICC and leave you be to sleep.  Let me know if you need the pain meds.”  I said.

I realized what he was playing at.  Sympathy.  He wanted me to feel sorry and say, “Oh let me call the doc and see if I can get something that will work.” No, I was not going to play that game.  The docs knew and were aware of the situation.  They wouldn’t have given me anything even if I had called.  Back at the nursing station one of my colleagues said to me, “Did you hear what he said when he came out to get a drink?

“No, do tell.”

“Yeah, he pretty much said this:  I can’t wait to get out of this place. First thing I’m goin’ to do is get a 12-pack of beers, sit down and drink the whole thing.”  she said.

Great, I thought, we fix him and he goes back and does everything he could do to ruin all the hard work we did.  It made me mad.  I knew that it wasn’t an insurance company that was going to eat this.  No, it was working folks like you and me that were going to bear the burden.  Yes, your tax dollars hard at work.  Here we were, paying (indirectly if course) to save someone who really did even want to be saved and who vowed to undo all of it the moment he left the hospital.  Now I don’t have a problem taking care of folks who aren’t as lucky as I am.  In fact I would like to do more things to help out those who can’t help themselves.  But in this case it was all I could do not to tell him exactly how I felt, and it wouldn’t have been in the most socially-acceptable terms.  Many people see this as a chance to start fresh, like getting a new lease on life and try to do anything they can to make sure it sticks. They take the lessons to heart and become personally invested in the process.  Some don’t. They pass on the opportunity.  They’re the ones that will keep getting admitted.  The ones that we will again and again until they drop.  We’ll keep tuning them up and sending them back out, until they eventually stay for months at a time and maybe get a celestial discharge.  If we’re lucky.

But I digress.  He got discharged.  And hasn’t come back.  Yet.

Chalk this one up as a split decision too – ’cause I don’t think you can ever win in this situation.