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…

How to Scare a Tele Nurse

Or, “oh shit!  That VT isn’t stopping!”

I’m walking into the nurses station the other night when I hear the “oh shit!” alarm ringing in the tele cave.  Y’know the one, that incessant, high-pitched dinging that is saying “Pay attention!”  Reflexes trained by my years on a tele floor I look up expecting to see someone bradying down, or maybe some nasty artifact, but instead I see this starting – and it’s not stopping!

Do I…
A.) Start screaming like a little teeny-bopper freaking out and run in circles?
B.) Shit my pants?
C.) Drop what I’m doing and high-tail it to the room in question?

Believe it or not, C is the correct answer.  Sphincter slams shut as I haul ass down the hall.  I bust in the room expecting to find a dude laying there, unresponsive, not breathing or generally not doing well.  Instead I see dude and his nurse clamly chatting.  I breathlessly ask, “Were you shaking the leads?”

“No” she replies, “What’s up?

Dude looks up and says, “Is my heart racing again?”

“Uh, yeah, he’s in VT.”  I say, amazed that he’s sitting there calmly chatting.  “Do you feel funny or anything?”

“Yeah, my heart feels like it’s going pretty fast.  But I’m used to it, it’s happened many times before, no big thing.” he replies nonchalantly, basically amused with the gaping look on my face.

So we hook him up to the bedside monitor, and sure enough, there it is VT, rate in the 150’s, BP is 100/53, he’s pink (ok, kind of yellow), warm and dry.  No light-headedness, no dizziness, he does admit to a little bit of chest pain, but in reality he’s in better shape that half the floor, except that he’s in this particular rhythm.

Prehospital 12-Lead ECG has a great quote on their wide complex tachycardia page, “If it’s a wide complex rhythm (fast or slow) it’s ventricular until proven otherwise!”  And that’s how we were treating it.  So we grab some labs, call the ICU team to come assess him and a 12-lead EKG.  Should we have called a Rapid Response?  Maybe, but we felt we didn’t have to.  He was stable.  He has had this many times before.  And he was sitting there cracking jokes with us.

So here’s the 12-lead:

So what to do now?  The ACLS algorithm for tachycardia with pulses starts with determining if the patient is stable.  Check.  He’s cool.  Establish IV access.  PICC line left upper arm.  Check.  Wide or Narrow complex?  Duh.  Obtain 12-Lead EKG.  Check.  Expert consultation advised.  Check, ICU team is here now.  Amiodarone if ventricular tachycardia or unknown, adenosine if SVT with abberancy.  Oh, wait…he has a history of WPW and 3 failed ablations.  Now what?

This is where expert consultation is really a good idea.  In our case, he’s now cracking jokes with the ICU team as well.  He’s still rolling along between 145-160 BPM.  We grab some labs.  Turns out his potassium sucked, magnesium sucked and his calcium critically sucked.  The Team decides that amiodarone would be a good idea and getting his electrolytes sorted out might help as well.  So we’re hanging amio, mag and they’re calling cardiology.  Mind you this is 2130 on a Friday night.  Do you think a cardiologist is going to come in at that hour?  Nope.  She says, “Oh, just have one of the ED docs cardiovert him and call it good.”

He gets packaged and ready to roll to the ICU, ’cause by this time he was pretty much a 1:1 and the nurse had 3 other patients she was already neglecting.  Grab the defib off the code cart, because with our combined luck (this nurse and I have a history of codes/RRTs) dude will decide to stop having a pulse once we’re between floors in the elevator.

The rest is rather boring.  A little bolus of propofol (yeah, we MJ’d him good!) and the judicious application of 100 joules of DC electricity fixed him right good.  One shock and back into sinus.  But it was a good thing he was in the Unit as they spent all night getting his ‘lytes repleted.

What could have been a very bad thing ended up being a very, well, fun thing.  Too often on our floor a busy night consists of incontinence, wrangling demented patients back into bed 30 times an hour or chasing naked psych patients down the hall, so dealing with a true cardiac issue was a rather refreshing change of pace.

Observation Lovin’

Our observation unit is lovingly called the Hooper Annex (Hooper is our local detox unit) as not a day goes by that we don’t have at least 1 in with ETOH-related issues.  But we get dumped on, a lot.  Usually it’s because the docs can’t or won’t make up their mind and end up passing the buck.

Can’t figure out what to do with grandma, but there’s really nothing medically wrong with her?  Admit to obs.

Oh, you’re drunk and it’s cold outside?  Admit to obs.

Gastropareisis needing dilaudid?  Obs.

I know that an observation unit is a place to send the patient if they just a little too unsafe to send home, but not sick enough to be admitted.  And it can be a great thing.  Take for example uncomplicated chest pain.  No family history, no pain at rest, pain resolved PTA, but you’re male, age >50 and smoke.  OK, perfect obs admit.  Grab some serial enzymes, an EKG in the morning, maybe a stress test and off you go.  Or when your troponin I jumps to 5.0, we can start beta blockers, integrillin and call the cath lab.  Either way, we’ve done the right thing.

On the other hand you get a patient that needs a little IV antibiotics for an upper arm abscess.  The labs from their PCP are borderline icky, not enough to say definitively one way or the other if in-patient admission is warranted.  What to do?  Based on old labs, because why would we pull new ones, just plan to admit them to obs.  Then maybe grab a few new labs to direct therapy.

But if things had gone the right way, y’know like accurately triaging the patient, doing a complete workup before sending the patient out of the ED, like with labs and stuff, we wouldn’t be looking at this trainwreck patient rolling by the desk looking at each other going, “Uh, oh.”

If you had drawn labs first you would have been floored by the lactate of 2.2, the WBC >18, a H/H in the shitter, mult. 4+ accumulations of gram-positive baccili and cocci and gran-negative baccilli growing from the wound culture you just did the in ED or the raging case of rhabdomyolysis with a CPK of 96,000!  Yes, 96,000.

Luckily for you,we queried this lack of workup where you found all of these values.   We had a funny feeling, y’know that gut-level, spidey-sense feeling that this patient is not going to turn out well without a higher level of care.  Thankfully you ended up placing the patient in the ICU so they could run pressors and hang lots of lots of fluid on his septic self, instead of on observation where we would have had to rapid response them to get them to the unit as they crashed before our eyes.  Yeah, good call.

Keepin’ the Beat

It looks like I’ve broken my streak.  I actually had almost 3 months without a Rapid Response or Code Blue on my shift.  It’s no more.  At least we didn’t have to do CPR on this little 40kg bag of skin and bones, just some airway support and off to the ICU.

But it got me thinking.  Thinking led to rooting around in my “book o’ fame” (my morbid collection of EKG strips of “bad things”) which led to me finding a couple of strips related to CPR.  Strange how a mind works.

Evidently, per the post-it note, these had been grabbed during a code last year where I did a TON of CPR.  Remember kids, a bad thing about being a big strong dude is that you get to do a lot of chest compressions.  I’m not dissing the ladies, I’ve seen many a round done by y’all, and you’re fierce, but for some reason whenever there is a code on my floor, yours truly gets roped in to do compressions.  Needless to say I had no need to go to the gym after that code.

My tele tech knows my predilection for interesting tele strips so he printed a couple for me.

First, near the beginning of the code:

CPR is in progress with a rate around 100bpm, stop to check for a rhythm, find VT, resume CPR, then shock.  This is why you resume CPR right after the shock.  That heart ain’t doing nothing.

Second near the end:

We’re still going fairly strong, figure the rate is around 80bpm, then nothing.  We called it about a minute after this strip was run.

In all fairness, they were dead from the get go.  Never once did we get a rhythm stable enough for transport, never a pulse, pupils were fixed pretty much from the beginning.  Morbid?  Probably.

But on to the beat.  They say 100bpm is the speed we need to keep when doing CPR.  It allows for adequate refilling of the ventricles with blood before the next compression.  In the midst of the controlled chaos of a code, keeping that speed can be tough when adrenaline gets the better of us.  So what do you do?  Keep the beat with a song.

We’ve all heard of “Stayin’ Alive” by the Bee Gees as the “perfect” CPR song.  Heck, I have it on my header.  My BLS instructor the last time around had a thing for “She’ll Be Coming Around the Mountain”.  There is the slightly more darker “Another One Bites the Dust” by Queen that fills the 100bpm measure.  Thanks to the American Heart Association, there is a large list of songs that fit the bill of 100bpm.  Some notables include:  “Kickstart my Heart” by Motely Crue (they would know), “Paradise City” by Guns N’ Roses. “Heart Attack Man” by the Beastie Boys and of all things, “Back to Life” by Soul II Soul.  The entire list can be found at Be the Beat, which is a website dedicated to educating kids about CPR, but here’s the playlist.

Will this help me set a new streak?  I doubt it.  As the rule of three shows, I have 2 to go before a new streak can start…

Hypotension Causing Nursing Hypertension

Hypotension Causes: Three Cases Of Severe Hypotension and Their Dramatic Response To Treatment.

I’m almost going to print this up and drop it in a couple of hospitalist’s mail boxes as they completely buggered their management of the hypotensive patient.
So here’s the story…
50-odd year old dude comes in with bilateral foot wounds, both medicine and podiatry are seeing him.  They start antibiotics and aggressive debridement of the said foot wounds.  To complicate matters, dude is “fluffy”.  Y’know, 400+ and we can’t tell if he is edematous or not.  It’s all fluff.  Instead of thinking sepsis, they’re thinking he needs to be diuresed.  Considering a history of CHF, not a bad idea.  But as he’s getting massive doses of IV Lasix, we’re talking drip rates in the 40mg/hour range here, his urine output starts to drop.  It dwindles, then nearly completely stops.  Bad sign, right?

As this is happening, his pressures are following the exact same path, dwindling down to nothing over nothing.  We’re talking 60/doppler and his pulse is dandy.   But here’s the thing:  he is completely alert and oriented, talking a mile a minute watching the Food Network.

This goes on for 4 days and 5 nights.  Yes, 5 fucking nights.  The nursing staff would call the the on-call staff, explain the situation and be rewarded with, “Oh, uh, turn off the Lasix.”  or “Uh, um…give him a 500ml bolus of NS.” The staff leave detailed notes in the progress notes about the situation so that they can be reviewed by the next day’s docs, but still nothing is done.  Maybe some more piddly-ass boluses that do a whole lot of nothing, but produce no net effect.

Finally on Day 5 (yes, Day 5) as his kidney function is truly in the shitter (creatinine is like 4.0), his ‘lytes are all wacky, his H/H is crap, he barely has any albumin, he hasn’t made urine in 4 days and has been getting goofy at night needing higher amounts of O2, someone decides to actually DO something.  2 units of packed cells, albumin q8, a couple of decent fluid boluses and dopamine.  Finally.

And as if by magic, he gets a blood pressure.  A real blood pressure, like 120’s/80’s.  He slowly starts to make urine.  His O2 need starts to go back to baseline and he’s no longer goofy.  Podiatry decides that now that he is stable it is time to do surgery to lop off the now gangrenous foot and get on with definitive care.

Here’s the thing:  we could have fixed him on night 1 had the on-call doc been willing to look and realize something was not right.  Could we have called a Rapid Response?  Yes, but he wasn’t truly in need of it.  He was relatively stable, with the exception of no blood pressure and no urine.  Besides, we figured that we could manage him on the floor without the ICU.

No one seemed to be cognizant of the fact he was in septic shock from those nasty feet of his.  That is until a prog note was written post-surgery that basically said, “acute on chronic renal failure and septic shock.”  Finally someone got it.

Can’t Put it Into Words

We had a code the other night.  It was by far the “best” code I’ve ever been privy to.  No yelling orders, no standing around waiting, no egos, just a concerted effort to save a dying (well, dead) patient.  The resident running the code was calm, cool and collected.  As we did our interventions he worked through the H’s & T’s trying to figure out if we could fix anything.  Outside of my ACLS megacode, I’ve never seen that.  But moreso, he asked the staff if there was anything that we thought he had missed.  And before he called it, he aksed if anyone else had any objections.  Truly it was a team effort.

But for some reason I can’t seem to shake it off.  I had no real connection to the patient, other than being the charge nurse.  They weren’t one of our frequent flyers.  But something reached ahold of me and won’t seem to let go.

Maybe it was the fact we found her already down in her room.  Or the fact I felt the ribs snap under my palms.  Or it was that we did CPR on her for 30 minutes, rotating between 2, then three of us.  Or that we threw everything in the code cart at her, and some things that weren’t,  but nothing seemed to help.  Our CPR was some of the best I’ve ever seen/felt.  We shocked her a total of 9 times.  She got tubed incredibly quick.  But it didn’t seem to matter.

For the last couple of nights, I’ve laid awake and thought about it.  Re-running it over in my head, which then sparks memories of other codes and then to the memory of running in to see them performing CPR on my little girl.  For some reason, this one cracked my shell.  Like the title says, I can’t put words to the feeling.

Maybe though, it re-affirms that I am human and that I do care, something that I’ve been feeling a great distance from.  Maybe I’ve grown cold over it all- something my wife mentioned in passing not too long ago.  Maybe this nagging sense of malaise over this event is me re-examining myself over this coldness and cynicism and the realization that I’ve moved that direction has left me a little out of sorts.  More than anything though, it serves as a reality check, a visceral reminder of what we do as nurses when things do go south.

I know with time this angst and malaise over it will fade.  I’ll make peace with the way I feel about it, but like all the others, I’ll never forget.

Evolution

We don’t often get to see evolving MIs.  Usually they go to cath lab and the ICU so serial EKGs are not available.  In this case, intervention had already been attempted but due to the nature and type of lesion no intervention was possible.  In a case such as this, surgical revascuarlization was the primary modality, but due to multiple co-morbid conditions including age, severe aortic stenosis (valve area in range of 0.55 cm²) and general deconditioning none of our surgeons would touch them.  Notice the subtle changes especially through the precordials.

20:00, Day 1

So, what do we see? First, Q-waves in leads V1, V2 and V3.  Second, ST-elevation in V1 and V2.  Third, ST-depression in V4 (slight), V5, V6 and flipped T-waves in Leads I and aVL.  Also present is probable left atrial enlargement and  Left Axis Deviation with an axis of around -30°.  Based on this you could theorize that the LAD and Circumflex arteries have some sort of lesion.  The patient is actually hemodynamically stable at the moment.  Previous to this, they had been in atrial flutter with a rate of 110-130’s with some instability.  The cardiologist who was on the floor at the time decided to cardiovert the patient, but as we were prepping to do so they spontaneously converted back to sinus rhythm.  Teetering on the knife edge of stability they enjoyed a nice nap thanks to the Versed we had pushed while prepping for the cardioversion.  It was a reminder to follow the checklist, including ensuring that the patient is still in the rhythm you’re going to shock them out of prior to giving drugs and shocking.  The cardiologist in the last rhythm  check notices that it looks different and at that very moment the tele tech comes running in saying, “They’re in sinus!  They’re back in sinus!”

Next, 24:00 Day 1, patient c/o 5/10 substernal chest pain.

Nothing too different, although you could say that there is a slight elevation in V3.  The other leads actually look a little better, especially the lateral leads.  No change to axis.  This was after one SL nitro though, so that dilation may have helped, one reason we try to get a 12-Lead prior to giving nitro.

06:00, Day 2

Now there appears to be ST-elevation in V3.  The lateral leads have calmed down, with just a touch of depression in V5, V6 and I, with flipped T-waves in aVL.

14:00, Day2

Kind of ugly now, eh?  Now we have questionable Q-waves in V1-V4 (there is a pip right before the wave drops), but fairly significant ST-elevation in the precordials.  Depression and inverted T’s in the lateral leads has returned.  Again this was during an episode of chest pain.

Later that night the patient started to decompensate fairly rapidly.  They had a drop in LOC accompanied by a drop in SPO2 to the low 80’s on 15L non-rebreather.  Lungs we very wet, obviously filling with fluid.  The nurse called the on-call cardiologist who ordered 80mg of Lasix IV, in addition to the 60mg given previously during the day that only got an output of 200ml.  Everything was starting to shut down.  We ended up calling a RRT to get a doc at the bedside, if nothing more than to see if there was anything within the patient’s advanced directive to help.

About a week prior to this, the patient had gone to the cath lab in the failed attempt mentioned above.  Angiography show a 99% occlusion of the left main and distal disease in the RCA, LAD and circumflex arteries.  The left main lesion was so bad that they interventionalist was unable to even pass a wire through, which means it was very, very tight.  They minimal blood flow the heart and absolutely no reserve.  With that in mind, the doc on the RRT realized that we could not fix the underlying problem that was causing the distress.  She spoke with the patient’s family who in the end realized that the patient didn’t have much longer, and made the patient comfort care.  They ended up expiring about an hour later.

Looking at these EKGs one could argue that the ST-elevation is actually LVH with a strain pattern. It certainly fits the criteria, especially when considering the patient had endured previous infarctions and had aortic stenosis, but I’m not completely convinced.  I’m no cardiologist, so I’m going with what I know.  But I am open to other suggestions.  It’s a sad case, especially as the family was still saying how they wanted to talk to the surgeon about open heart surgery the morning of Day 2.  Luckily, we were able to use the means available, notably medication, to give some comfort at the end for the patient, even if we couldn’t’ fix what was wrong.

Dear Doctor.

Letters I wish I could write, but never will.

#1

Dear Doctor Dumbass,

I realize in your three years of residency that you have seen and taken care of many patients with syncopal episodes. I know it in fact. But why this time, in spite of report that the patient lost consciousness for a full minute as he DFO’d, and not because he hit his head, did you write his activity to be up “ad lib”? You’re lucky us nurses can think for ourselves and suggested to your patient to stay in bed until we got him a little more rehydrated and then get out of bed, but only with help.

We know and understand that this is a small concept, but we’re big fans of patient safety and having someone pass out on you tends to sour our night. We would rather not have to scrape your patient up off the floor they hit as they passed out and fell. And honestly, the incident report takes far too much time to correctly fill out. Time that is spent saving patients from themselves.

Thank you,

Your Floor Nurses.

#2

Dear Doctor Asshole,

We would like to apologize for dragging you out from your peaceful slumber in the resident’s quarters when we called an RRT on a patient that needed a little extra special attention. We could tell by your rumpled clothes, lack of spark in those half-shut eyes of yours and the sheet impressions on your face that we had roused you from a good night’s sleep; and we apologize.

That said, do not treat us like shit. We have the right, no the responsibility to call a RRT for whatever reason, especially if we feel our patient is having an acute decompensation.  We are doing our job.  Do not belittle us by yelling over the presentation to you saying, “Why did you call an RRT?” with a sneer on your face and dismissive tine in your voice.  While we wanted to say, “Just to wake your sorry ass up,” we didn’t and pointed out the patient’s labored and frothy breathing, the patient’s heart rate of 170 (one which your colleague Dr. Dumbass hadn’t placed on tele on admit) and SPO2 in the 80’s with a NRB mask on. We asked for your exalted guidance and inspiring leadership in a tense situation made only tenser by the fact you are a fuckwad, who speaks to family, the husband of the poor woman about to buy herself a tube, the man who has stood by her side and cared for her every moment of her end-stage Parkinson’s disease, who bought all the necessary equipment, including a Hoyer lift, to care for her at home, lambasting him about his decision to keep the love of his life a full code, in spite of her terminal condition. Refusing to believe him up to the minute where that man tells you to, “Intubate her.”  Love drives us to do what many see as irrational things, but it is not our place to judge, especially in front of the loved ones.

And by the way, with an EKG with a rate of 150, those little triangular deflections in the EKG are not P-waves, see how regular they are? See how they merge into the QRS complexes? Yes, Dr. Asshole, that is a textbook example of 2:1 atrial flutter, not sinus tachycardia. It’s sad that the lowly floor nurse can spot that and you can’t. It also really sucks when your attending tells us that you were wrong and we were right. We’re sorry that you are trying to make up for some obvious lack in your life (may I say manhood…?) by being a complete dick to everyone around you. It will not win you friends. We will chafe under you ham-handed management and surly attitude (I mean really, you aren’t a surgeon or cardiologist and don’t have the chops to back that attitude) until management gets the hint that you are more of a hindrance than help, if only from the sheer volume of write-ups with your name on them.  Until then go find something else, may we suggest a 2-seat convertible, to fulfill your manliness.

So pardon us for being frank, but we figured you needed to be taken down a notch or two.

Thank you,

Your Floor Nurses.

Passive-aggressive? Maybe a little. The sentiment is there though. Two stellar examples we shown to me this last weekend. While it may not seem like a lot, it is a trend of things with these two. You just scratch your head and do your best for the patient and family.  Keep them safe and as the wise man once said, “Air goes in and out, blood goes round and round; any deviation from this is bad,” we try to keep that premise, everyday.

Mr. Black Cloud

Yes, that’s me.  A little black cloud of despair that casts a pall of shadow across any bright and sunlit unit.  It follows me, but only when I am in charge.  I’m still not one hundred percent sure of it, there may be other variables to the equation, but the only constant is me.   Let me explain.

The very first night I was flying solo as charge started with a bang.  OK, well, kind of a whimper, but as I am the superstitious type it was a bad omen.  It was innocuous.  Simple problem.  The copier wouldn’t work.  I’m sitting in the copy room, the walls closing in on my as the seconds count down until my staff arrives and I don’t have their assignments ready. I’m sweating like a hooker in church and ready to blow chunks.  Anxiety attack?  Only a small one.  And over what? A copier that I can’t seem to get to work.  Yes, blown waaaaaay out of proportion, but I really wanted things to be smooth.  Yeah right.  The silver lining was that all the patients ended up with nurses.  No harm done really.  Until 2am.

Report had it that she was circling, but no one knew how fast she would go.  Fast.  Six hours after changing her code status to DNR she was gone.  So what do I get to do my first shift?  Yep, post-postmortem paperwork, which incidentally I did not even know the location of.  But with help it got done.  “OK,” I said, “I can handle this.”  Second night, not so bad.  Just juggling beds and nurses.  Not a big deal.  Not that big of a black cloud.  Maybe partly cloudy.  The other relief charge nurses told me that having a patient expire on your first charge shift is almost like a right of passage:  nearly all had it happen to them.  Small solace that.

But it was the last weekend that my true status was cemented.

The night started off well enough.  We were full.  Usually when I go to bed rounds to let the supervisor know my open beds, the number is large and no one else has beds.  I usually have to come back and tell the nurses that, “Guess what?  We have the only open beds.  We’re the admit bitch, anything that comes in is ours.”  Not tonight.  I had one bed.  Female.  And all the admits were male.  I like that, makes life easy.  Gives me time to help out my nurses.

Then I hear the call for help echoing out of one of the rooms.  Patient is unresponsive.  RRT is called.  Then something weird happened:  time slowed down.  Not because we were moving fast, but because nothing was being done.  The resident was ordering squat.  Nothing.  Nothing was really being done, we’re all waiting with baited breath for something, anything.  Labs?  Meds?  We have extra O2 on.  Anything?  Finally then, “OK, I don’t like what’s going on with her airway.  Let’s get her to the Unit.”  “Thank God!” I say, more for the relief of something actually being decided, but also for the floor nurses’ Code credo, “Get them off my floor!”

Off to the Unit we go.  Nothing like a brisk walk in the morning to get the blood flowing.  We’re almost to the pod the patient is destined for when what comes overhead but, “Rapid Response to Wanderer’s floor!”   Crap, another one?  Sure enough as I head into the room I hear, “Yeah, her CBG is 12.”

Not good.  D50 is pushed, nothing.  No change.  Then narcan is given.  And surprise, the patient wakes up.  Crisis averted.  We have the resident write orders for PRN Narcan, just in case.  You see, with altered liver and kidney function all those wonderful little opiate molecules were just recirculating round and round.  Thru the night more narcan was given as its effects did not outlast the drugs.  So every time they would drift off to unresponsive-land, they got more narcan.  And they woke up.  Go figure.

So yes, reputation beginning.   I knew from the start that the next night wasn’t going to be a fun ride either when my fortune cookie with dinner read:

“Do not unexpected situations ‘throw’ you.” (in bed)

And what do you know?  Another RRT.  Another trip to the Unit.  Same nurse as the first the night before.  Hmmm, so it’s either her or me, hard to tell.  All told, 3 RRTs in 2 nights.  More than the previous 2 months combined.  I think I have  black cloud indeed.  Did I mention the copier crapped out on me the night of the double RRT?

I think I do have a black cloud.