Whatever, Just Put Them on the Monitor

 

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.

The Shakes

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By the time I got home the adrenaline was finally starting to wear off, the shakes trailing off.  I don’t really remember the drive, it was an automatic drive home.  I was aware, but detached as the images of what happened to my patient just minutes earlier kept running through my head.  Those images were accompanied by the snippets of conversation, the shock and fear, the cool, clammy sweat sticky back of my t-shirt as it clung to my back.  Numb, but not comfortably.

How quickly things can change with our patients.  One moment you’re waking up not feeling well, but OK, waiting for surgery, the next you’re vomiting up copious amount of blood and huge chunks of clots.  How strange it must be to not understand what happened because you went totally unresponsive right before you vomited.  Did you hear your nurse yell out in fear “Can I get some help in here?!  Someone call a Code!!!”

How odd it must be to open your eyes and see 15 people swarming your bed, frantic in their energy asking questions, asking you how you’re doing, sucking something out of your mouth.  Do you feel it when you vagal out, go asystolic, vomit more blood and have someone start pumping on your chest?  And when you ask, “Did I throw up?”  the the nurses tells you that you did, but all you can worry about is that you might have lost control of your bowels.  What goes through your mind when the nurse who has taken care of you for the last 2 nights is asking you to “Stay with me!”  Do you know when your blood pressure is 60 palp?  That you’re pale, diaphoretic and ashen?

Does riding in a bed moving like the furies are after it down the hall cause motion sickness?  I’m guessing that the worried looks, the terse simple descriptive language the nurses and docs are using, the speech of people under pressure must worry you.  Does your mind rebel at the unfairness of it all?  Did realizing you had stomach cancer make you mad?  You were a healthy guy.  Sure you drank, but you sobered up years ago.  Yeah, you smoked, but otherwise, healthy.  No chronic medical conditions, just some elevated lipids.  In fact your doc at your last yearly check-up said you were about the healthiest 80 year old he had seen in a long time.  Or is the only thing you’re thinking about is your wife of 50 some odd years and whether you’re going to see her again?

I know that when you got to the ICU you vomited more blood and clot chunks.  You looked incredibly pale, blood pressure barely registering.  There was blood all over the floor, all over you, all over the bed.  I wish you could see the cluster of docs outside your road, the 7 nurses around your bed, the cluster of medical knowledge all focused on saving you.  I wish I could tell you that it was going to be OK, that we’re going to take care of this, but deep down I know I can’t.  You’ve lost a lot of blood, it’s got to be close to 3 liters, blood and huge gelatinous chunks of clot, like something tore loose inside of you.  But you were in the best place and I was in the way.

It was the fastest 30 minutes I can remember in a long time.  The adrenaline was still surging as we brought the bed back upstairs but as I began talking to my colleagues the shakes started.  I knew they would, was waiting for them.  The shakes, the weakness in the knees, the self-doubt came crashing down, barely held back by an iron will.  It’s odd how I can remember bits and pieces, little flurries, but not a seamless narrative of the whole thing.  Maybe it’s a protective thing.  I remember the looks on my co-workers faces, the awe, the respect, the one who said, “I want you in my code, you were so in control.”  If they only knew.

If they knew that I spent the drive home going over every little bit of the previous 12 hours.  Could I have done anything differently?  Should I have checked your vitals at 4am instead of letting you sleep?  You had been rock-solid stable all day, all night, no sign that anything was amiss.  I know rationally that this was a quick thing, bright red blood spewing out is a rapid thing.  The clots?  Well the EGD pics were beyond nasty, huge masses of clot on the wall of the stomach.  It is like something broke open.  Still I wonder if there had been a sign early, if there was something I missed, or if it just came down to when you went unresponsive and started to vomit up blood.  You should know though, that I went home, and even though I’m not a religious guy, said a prayer for you, knowing you needed all the help you could get.

I just looked down at my hands, the shakes are gone.  Finally.