It’s Been A Week

It’s odd, I figured this unemployment thing would be like a vacation.  Sit back, relax, catch up on things left unread, do some housework while slowly getting things for the imminent move together.  I figured I would not miss working, prepping for work or the actual time spent going to work.

Yeah.  Wrong on all counts.

Admittedly I’ve done a fair bit of relaxing.  There have been many days of sitting around in sweats like some somewhat thinner suburban version of Jabba the Hut, dropping whatever snacks were within reach into my maw, ordering minions to do things (at least in my head).  I’ve spent some quality time on Twitter, on some blogs, scoping out new places to ride when we move, but have done little of anything constructive.  The place looks pretty much exactly like it did the week I stopped working.  Packing?  Psshh.  Attacking the list of things I need to accomplish for the week?  Did (the easy) 50%.

Never thought I would say it, but the hardest thing is not going to work.  I see the #nocshift tag come up on Twitter for all those headed to slay the dragon of work and while I may be there in spirit, I’m really just an impostor now.  I wish them luck and go back to doing nothing of consequence.  But it’s the odd things that seem to mean the most to me.  Not buying food specifically for work.  Not staying up ’til all hours to readjust my internal clock to stay up for the next three nights.  Not having the in-person interaction with my friends as we strive towards a common goal.  It has made me slightly off-balance and I don’t like it.  Coming from a long line of Scandinavian hard working folk, the need to work is etched indelibly into my DNA.  Go too long without and I become insufferable to be around, pacing like a wild animal trapped in an enclosure but unable to do anything.

Worst though it has allowed my fear of not getting work even more real.  It has allowed that nagging voice, the one that I used to continually tell to “shut the fuck up!” a little more volume.  That little voice has been very, very talkative of late.  Doubt, the killer of initiative, has been working overtime.

All this after only a week.  I’m going to be a psychic wreck by the time I get to Arizona.  And I will have probably driven my wife insane.

At least though, things are slowly coming together.  It appears we have a place to call home lined up.  There seems to be some jobs in the area that I could pursue.  I just have to realize that things will take some time.  This isn’t going to happen overnight, no matter how hard I want it to.  The last time I was unemployed was so painful, more for factors beyond not having a job/income, that issues I thought I had dealt with long ago are bleeding into the current discussion which makes this more stressful.  I have to remember that this is not like last time.  I have experience.  I have money coming in.  I’m not running from death, disappointment and despair.  Instead I’m running to something new, exciting and different.  And you’e all along for the ride!

Night Shift Blues

The worst shift I ever worked was a 3-7:30 shift loading freight onto planes in Portland. Wet, windy, cold on the damp days, hot and windy when it was warm, and I had to walk uphill both ways to work. But at least there was time to deal with normal life that working night shift doesn’t give me.

My manager remarked to me that night-shifters tend to, “have a bit of chip on our shoulders, almost like the world owes you something.” Damn right I do. I’m up when most sane and rational people are asleep. I sleep when the rest of the world is doing there thing. If someone is loud, obnoxious when day shift sleeps, they can call the cops. Me? I’m outta luck.

So yes, I have a chip about it. The world wants 24-7 care, a 24-7 society, but does little to accommodate it. One of these needs has to give. Soon.

Gettin’ Ran

It was night three, about 3am.  I had just gone down to the cafeteria to get something fried and salty to satisfy the ravenous beast in my gut.  I had about 5 of the fries while still warm as I walked into near pandemonium.  It was like someone turned the crazy on the minute I left the floor.

Compared to the previous two nights, this one hadn’t been too bad.  While earlier in the week it had been “grab your ankles and hold on!” tonight was a little better controlled chaos.  Instead of a rapid response we calmly sent the patient with a pH of 7.19 and a pCO2 of 95 to ICU for BiPAP.  Instead of getting hit with a CVA admit with no orders at shift change, the only patient we admitted came with orders and hours after shift change.  It was better.  Kind of.

While technically we weren’t short, we were.  We had two floats filling in for the one we were short and the one we floated away to step-down, but strong they were not.  They had the easiest patients on the floor, but were barely keeping head above water.   In essence we were short as they couldn’t help the rest of us.  And the scheduled aide?  Yeah, stuck in close observation with the paranoid, impulsive, delirious ICU transfer out.

I don’t remember a whole lot after 3am, it’s just a blur as we ran putting out one fire after another.  Your previously calm patient is now fucking nuts?  Hey isn’t that your patient trying to escape out the fire door?  Hey, my patient sounds like a stridorous 3 year old and has that “oh shit” look in her eyes as she uses every muscle in her body to breathe.  Bed alarms to my left, call lights to my right and I’m stuck in the middle with you all.

Our only saving grace was the 3 of us left from our core staff formed a tight team, picking up where each left off, answering call lights and bed alarms without the petty stuff that gets in the way.  What, you need meds on 97?  Got it.  Can you tuck 93 back into bed?  No problem.  Tight teamwork saved the night and got us through until 0705.

No falls, no restraints and chaos reigned in by the time day shift rolled in the door.  It’s how we do it.  It’s how we did it.

Stupid Questions

“Uh, hey Wanderer?  You said the super-pube would just easily come out after we deflated the balloon, right?” the nurse asked me from across the hall.

“Yeah, might have to tug a little, but should just be able to remove it and swap in the new one.”  I said.

“It seems like it’s stuck…can you come take a look?”  he said.

Gown up, glove up (isolation rooms are the best!) and head in.  The catheter is in the stoma the nurse looking at me with question marks above his head.  “You have all the saline out of the balloon?”

“Yeah, can’t pull any more back.”  he confirms.

I reach down and grab it, give it a good tug.  Nothing.  Twist it a little around.  Still no dice.  Twist and tug.  It’s not going anywhere.  Short of putting my foot on the patient’s chest and pulling, which probably is a bad idea, we’re not getting it out without expert (read: someone with an MD to take responsibilty) help.  I say as such tot he nurse and suggest he call the intern on duty.

The intern calls back and the nurse explains the situation.  She proceeds to ask, “Well, did you deflate the balloon?”

It’s a good thing it was him and not me.  He was cordial and didn’t roll his eyes too much.  Me, at that point it would have been, “Really?  Do you think I’m that stupid to not deflate the balloon?  Really?  I’m not some novice who’s never done this.  For f*cks sake, give me at least a little credit here!”  That’s why he called, not me.

Be careful of who you ask stupid questions of…

You want what?

“Hi, Dr. Heart, I’m calling you about Mr. I’ve-gone-crazy who your partner did a pacer generator change on today.  He’s become very agitated and combative since the start of our shift.  I need something now to calm him down as nothing else has worked.  Would something like Depakote sprinkles or Zyprexa, maybe even Haldol be OK with you?  said the nurse into the phone.

Seriously, the guy was freaking out.  Every non-pharmacological method we have in the arsenal had been thrown at him.  He was confused and rightfully so.  It’s not nice to put folks with dementia through surgery, it leads to some very funky things.  He went from perseverating over his pants to perseverating over his wheel chair, then he wanted to be in bed, now in the chair and wherever you put him he wanted out of it.  Did I mention he could not stand and bear his own weight?

The other nurses looked at me imploringly to help his nurse out.  “You’ve got to do something!” they said to me.

“She’s his nurse, and yes, we’re doing all of her work for her, but I cannot call the doc for her.  I don’t know the details, I don’t know enough about his history to state my case for what I think is needed.  But I will talk with her.” I said.

The nurse came up to me minutes later and asked what to do.  I reeled off the things that might help, meds that we have used time and time again in these situations.  She agreed and went to call the doc.  Above is how I pictured the conversation (she likes to hide in the med room or pharmacy office to call).

I can surmise how the rest of the above conversation went.  “You want what?  I have no idea about any of those meds.  He’s agitated?  Um, not really used to dealing with this, is he covered by Medicine?  No?  Really?  I don’t even know what the doses would be for those meds in this situation.  Uhhh…how about some Ativan?”

To which the nurse readily agreed.  Really we would have taken anything at that point.  This is not to say that our cardiologists don’t know what they are doing, they’re just not as adept at helping us handle the agitated and combative elder as say our medicine interns or geriatrics service.  It’s a level of comfort.  Our geri docs would readily agree to something like Depakote far faster than Ativan, but it’s their milieu.  Would not want one of them dropping a stent in my patient.  It’s what you know.

And the Ativan?  It worked for a while but he ended up with a sitter by daybreak, still confused and combative, but staying safely in bed.  Lesson?  Avoid general anesthesia and things like Versed and Fentanyl on demented elders:  it makes them worse.

(Am not saying to not do procedures on folks of advanced age, make sure you give us the tools to manage them and ensure their safety post-operatively when you do!)

Dirty Old Man

or,  “How I will be when I’m old and demented.”

They say with age and dementia, decorum goes out the window and we revert to our true selves.  Or at least to our basest desires.  It doesn’t help however when we egg you on.

“Oh my God!” breathlessly says the nurse as she comes out of the room in a rush to grab something from the clean utility room.  “He’s a perv!”

About ten minutes later I learn why as our aide comes out of the room laughing and tells us why.

“So he has ‘sweet’ and ‘sour’ tattooed above each nipple, that’s a new one even for me!  As we’re cleaning him up I say, ‘Oh, and this is full of piss and vinegar, right?’ pointing to his peri area.   As I’m saying this he reaches over and caresses and pats my ass saying, “You better believe it baby!”  I almost died trying to keep a straight face!”

Passed it off to the next charge nurse that he was a little, “grabby.”

Culture of Coddling vs Eating Young

Not all that long ago I was a fresh-faced new grad, eager to explore the great wide world of nursing.  School was done, externship was over and I had passed the dreaded NCLEX on the first try.  I was ready.

Yeah right.

My first year was brutal.  Trial by fire, eating of the young, stress migraines and an overwhelming urge to run screaming as fast as possible away from my job and go work at McDonalds, that encompassed the first 6-8 months.  Then as if by magic, I realized I wasn’t struggling, I wasn’t hating work, I didn’t get sick on the way to work and people were asking ME for answers instead of the other way around.  I couldn’t tell you when it happened, just that it did.  Having been through it I know that it made me a better nurse.  That hell I went through toughened me up, made me become organized as a survival technique, taught me how to juggle the needs of my patients with the duties I needed to perform whilst maintaining a sembalnce of sanity.  And it worked.  It was kind of like boot camp:  break you down to build you up.

Since then I’ve precepted new grads, been a mentor of sorts to them and tried to make their first year a little less harrowing, but still instilling the fire they need to survive.  I don’t practice eating of the young, it’s counter-productive and will drive promising new nurses right out of nursing, or at least off of your unit leaving you back where you started: short handed.  But I do believe a little bit of “tough love” is needed.  Our job is not easy and the sooner you accept that it isn’t all candy and rainbows the sooner we can build you into a competent nurse.  Not saying that you’re crying on the way home everyday, but not shielding from the rough days either.

Our system just bought into the Versant Residency Solution, which is a systematic residency program intended to rapidly prepare new nurses.   “After only 18 weeks, trained observers report that Versant RN Residency graduates achieve Nursing Skills Competency ratings that are slightly above new graduate comparison groups who have been in professional practice for nearly a year and a half (17.1 months).”  Sounds awesome.  Wish we had something like that when I was starting out.  That would have made my first year a little bit better.  Or is it just delaying the inevitable?

Our RN Resident is with us for 18 weeks.  18 weeks of being precepted before they are on their own.  2 days a week in classes, 2 days a week on the floor.  It’s a tough schedule, worse for those that drew a night shift slot.  But in our over-saturated market many new grads were willing to sign over their first and second born to get a nursing job.  For 50 something slots, over 500 newly graduated nurses applied.  It’s that desperate here.  Truly these are the cream of the crop.  But for 18 weeks they are coddled into nursing on the floor.  I had 12 shifts with a preceptor, and was told straight out that by shift 9 or so I would be taking a full load with the preceptor merely supplying help when needed.  Our poor resident is struggling still to take 2-3 patients a night and they are already past day 12 and those running the program have told the preceptors that the residents aren’t expected to take a full load until the final weeks of the residency, if even then.  For 18 weeks we expect less, are allowed to expect less and not to push as hard as we might have before.  We’re coddling.

Do I expect new nurses to go through the same shit I did?  It sounds like it.  But I truly believe that there comes a point where you can no longer hold their hands, no longer allow them to sit idly by, skimming along with help from their preceptor:  it’s time to fly!  The 18 weeks is doing a dis-service as it is not making them fly on their own.  What made me a competent and efficient nurse?  Stress.  Pain.  Being kicked out of the nest and having no choice but to fly.  Did it suck?  Yeah, but I know that I’m stronger for it.  This coddling aspect is so ingrained in our culture, from the “everyone wins” school of thought in sports, to getting a 4.3 GPA on a 4.0 scale,  to overprotective parents, that we can’t just let people go and see how they function on their own.

Since I started on my floor, it has changed drastically.  The old battle axe nurses have moved on, now you’re more likely to get help when you ask  rather than a dirty look or eye roll and generally it’s a better place.  Being let fly here is far less daunting than it was when I started, there is support whereas previously you really were on your own.  But, due to the rules of the program we can’t let our residents fly on their own.

I know that people will ask, “So, are you doing anything to help the resident?”  Yes, the preceptors (there are three of them) and a couple of the charge nurses have talked about ways to help them.  We don’t want them to fail, but we don’t want the end of the 18 weeks to be a huge issue either, where all of a sudden you’re flying free and haven’t developed the skills to keep aloft.  Who knows, maybe this idea is great and it will produce incredible results – that’s at least what the program developers say.  But I have one lingering question:  how can you be as good as a 18 month nurse at 18 weeks when you’re only spent 12 of those weeks actually caring for patients?  Book learning is great, but it means nothing until you get to use it.  It is the actual act of caring for the patients that brings the book knowledge into focus as Ricky Gervais said, “Without application, knowledge is pointless.”  We’ll see how it end in about 3 months.

Rapid Response Teams: Excuse or Tool?

I know this has been discussed ad nauseam already, but I had to weigh in.

Thanks to an article out on Medpage Today, Rapid Response Teams Sign of Poor Bed Management, the whole idea of Rapid Response Teams has been brought into the spotlight.  The article’s premise is that poor bed management is the cause for Rapid Responses to be called.  Bullshit. 

Code Blog sums it up nicely by saying,

I don’t believe RRTs are called because the patient was already in bad shape and assigned to a low level of care.  I think they are called because stable patients just stop being stable sometimes.

Are there times where over-crowding and poor bed management are the cause?  Yeah, if it is crazy busy, the nurse might miss subtle signs or the patient is sent to a floor of lesser acuity, but these are the exception rather than the rule.  I can count on my hand the number of times I’ve called an RRT, of course now I’ve now jinxed myself, but each time it was from a rapid change in patient condition.  There have been times where I could have called an RRT, but managed it with judicious use of critical thinking and calls to the doc.  I think that some nurses use them as a crutch instead of critically thinking a situation through, but not because a patient was wrongly placed.  Like I noted above, there are times when the patient is placed wrong.  When our observation unit opened we had several times where they went from Obs to the Unit in a very short amount of time.  But again, these we patients who rapidly de-compensated – and a couple that never should have gone there, but those are the exception.

Have the authors forgotten that a hospital is an acute setting?  It’s not like these folks are healthy!  And thanks to the rise of observation (outpatient in the hospital) those who are admitted in-patient are the sick of the sick.  Having a resource to get help quickly is a godsend.  Sometimes all you need is some stat meds, or imaging and labs , or just someone to look and say, “Yeah, they’re sick!”  And sometimes you just need to have the ability to transfer to a higher level of care without jumping through hoops.

Even if we have the best patient flow possible, appropriate bed placement each and every time and proper resource management, there still would be a need to the Team.  Patients crump.  The article never addresses that simple fact.  It’s far easier to point out structural issues than the reality – of course structural issues are somewhat easier to fix.  Schedule better to make better use of the nurses you’re already overworking.  Staffing plays an important role in this as well.  A nurse that is stretched too thin can’t take the needed time to adequately assess their patients.  When you 5, 6, 7 or more patients at a time, you’re running and even the most perceptive, mind-reading nurse can catch a patient decline if they’re stuck cleaning and doing a massive dressing change because the wound is saturated in stool of a 400lb quad with the 3 other nurses on the floor because it takes at least 4 to move the patient safely.  That’s when the easy things to fix fall through the cracks, hence why we need a team to “rescue” the nurses.

It’s a complex multi-layered issue to which there are no simple and easy answers.  It impacts staffing, scheduling, patient flow and the vagaries of the human condition.  But would I choose to work somewhere without the back up of a RRT?  Not easily.

Record Setting Month

I’m glad August is OVER!  What is normally a shit month in my life was a shit month at work too.  Low census, poor staffing, sick-ass train-wrecks and all the goodies of a urban tele floor.

But truly I’ve had some records shattered.  We see far out and funky lab values all the time, but these were some doozies this month.

And the Winners are:

HbgA1C:  14.6!  Also had a 13.9 as a runner-up.  Both patients with Type I diabetes, both young, one with OK support, one with none.  We worked the diabetic educator to the bone trying  to teach these young’uns to not end up destroying themselves.  For those playing along with the home game, <6 is good control for diabetics.  And when you translate that to eAG (estimated Average Glucose) you get 372mg/dl and 352mg/dl.  Bad mojo.

Worst Case of Thrush EVER:  Candidal Esophagitis, from the oropharynx to just above the lower esophageal sphincter.  And in a twist, the patient was not immuno-compromised.

Highest WBC in a non-cancer patient:  68.8.  Yes, 68,800!  And it had jumped from 48,000 less than 12 hours earlier.

Lactate:  10.8.  Of course what do I say?  “Last time I saw a lactate that high we were coding the patient.”  Sure enough the patient did expire (they had the nasty white count).  They were sick with a capital “F”.

Dumbest idea of the month:  dude comes in drunk and complaining of nausea and vomiting.  After being triaged he goes to the bathroom and pops a couple of poppers, promptly turns grayish-blue with  a pressure of 50 and a raging onset of methemoglobinemia.  At least he was in the ED when he did it.

Oh, and for two Fridays in a row, had rapid responses at shift change…a helluva’ way to start the shift!

I hope September is better…

Happy Birthday

Happy Birthday Mia Rose.

You would have been 4 years old today, August 10th, but you left so suddenly and so unexpectedly.

I know it’s been 4 years and maybe I should have moved on, moved past or otherwise just moved, but some days I find it hard to do, well, anything.  I still have the snippets of images in my mind when I reflect, quick flashes of memory that can take me from normal to an emotional wreck in .25seconds.  It’s changed me.  Your life changed me.

I think of all the milestones you would have had, walking, talking, temper tantrums, special simple moments, that didn’t happen.  I wish I had reported the nurse who we think killed you, but the shock and trauma of it all had rendered us numb.  It’s like I let you down and now can’t forgive myself for it.

At least we’ll always have those small quiet moments where your Mom and I would just hold vigil in your little room.  The nurse would leave us alone in there with you, giving us some space to be a family.  It was dark in there, lit only by the blue bili lights and we would talk and dream about our future, your future.  We knew you heard us as you would calm down and seem to rest easy hearing those voices you knew so well if  only for a short time, the voices of you parents.  I treasure those moments.  When things were calm.  When things were hopeful.

All too often though I forget those special moments and remember the sheer terror of running into the NICU seeing them doing half-hearted CPR.  It was so bright in that room, thing were washed out by all the light streaming in but all I could see was your lifeless body and them looking at me.  I remember the pity on their faces, the pain they mirrored when they asked if I wanted them to continue.  I had to tell them to stop.  I let them stop.  I didn’t want to, but I knew it was far too late.  When you died, so did a little bit of me.  And I’ve had an empty hole ever since.

There’s still something missing in our lives.  Our life would have been nearly perfect with you in it, complete.  There are days where the rage is palpable, the sadness suffocating, the hopelessness immobilizing and I get into a funk so deep that all I want to do is hide in our house and bury myself into TV, praying to numb myself.  Perhaps this year is harder as I stopped the antidepressants, so I’m finally feeling the emotions again.  And while it feels good to feel again, it’s not easy.

But I’m trying to focus on the good.  You were with us for 8 days.  And what an impression you made.  Even though you were so young and so fragile, we could see your personality beginning to develop, our tiny little individual.  I’m lucky to have known you, one might say blessed (although I hate saying that I’m “blessed”…).  So I’m going to minimize the bad while remembering the good.

Happy Birthday baby girl!  We’ll never forget!

You can read Mia’s story here, here and here.