skillzzzzzzzzzzzzz

there is a certain feeling of accomplishment that comes from doing a job well. like when you have had to use all your critical thinking skills, maybe caught something about a patient that was a little bit off that ended up making a difference or saving a life. or making a connection with a family member having a hard time letting go of grandma or grandpa. or running all night transfusing units of blood trying to stay ahead of a bleed, and successfully 'reminding' the physician to order lasix in between units of PRBC's. sometimes the night is such a high i have a hard time winding down in the car on the way home. not a high like.....a good high sometimes, like you just finished a great endorphin-releasing run or a really amped up concert. but more like you just fought a good fight....or, i dunno, it's hard to explain.
on the other hand, i hate the nights when i get my ass handed to me. when your A game just isn't there and you miss stuff......as exhilarating as it can be to Find the Big Thing or Prevent the Tragic Mistake, that's equally how bad it can suck to MISS the Thing that Kills Your Patient. for the record, i haven't yet Missed the Thing that Kills my patient, but i've def come close a few times. what i have done a few times is not Miss the Thing that Kills my patient, but had my patient die or end badly anyway. that sucks. i'm not sure what this piece has to do with skills, (i think i had a different post in mind when i started), but there you go.

things you can't say to your patients #2

to the sweet sweet 60 some-odd year old lady with the silicone breasts of a 20 something year old hollywood starlet, 'wow, these are some very nice boobs. very symetrical, perky and firm. in fact, they are so firm, i can't even listen to your lung sounds to assess your pnemonia like i'd like to because they aren't sagging down under your armpits as your-age appropriate boobs should and would be.' what i can't help thinking about everytime i encounter a set is that someday, all that will be left will be a bunch of bones and two perfectly shaped, symetrical bags of silicone sitting in a fancy wooden box. that would make a fun halloween costume though, huh? i'd have to explain it to everybody however, and that would get old fast.

things you can't say to your patients #1

.......when you are placing a foley in someone's penis. 'hey man, you have a REALLY large penis. way to go. does it get even bigger when it's erect?' or to the girlfriend, 'wow, looks like you are one lucky lady.'  it wouldn't have mattered anyway, the kid was only 18 and probably a virgin anyway. that probably means he wasn't even done growing......geez, imagin that.

Maximus, Brutus, Octavius

i have three boys. if you can remember far back enough, i used to only have the one boy. here's what happened. we got pregnant very easily with Max. like, first time we tried, boom goes the dynamite. so we think to ourselves, well, we must be very fertile. awesome. years go by, we think we can handle another, so we try for bebe number 2. and try again. and again. and next month, we try again. no dice. what?!?!? finally, after a YEAR, we got Brutus. so..............now we're like, well, we must not be that fertile. and maybe we weren't as careful, you know, as we should have been. sooooooooooo, some how, when Brutus was only 6 months old, surprise! we're pregnant again. oh joy! right, honey? those are tears of joy, right? honey?
oy vey. that is hard. this is hard.  two boy bebes, 15 months apart, not so much fun. someday it will be worth it, i hope. man, it is hard now. hey, at least i got a cool minivan out of the whole thing.

ketchup

having two bebes in two years is HARD. seriously. I wouldn't recommend it to anyone. also, not having a fully functioning laptop kills your blogging career, but mostly it was the two bebes in two years thing. anyways, i'm back. did i miss anything?
i have missed blogging. i have a lot of catching up to do. i have really missed grumpy, nurse k, head nurse, new nurse in the hood, and scores of others. i have missed having a creative outlet to unwind and spew my emotions about nursing. hopefully i really am back.
where do i begin again? who am i now?
i guess i am a more experienced nurse. three years in an icu will do that to you, i guess. there is very little that comes my way now that i don't have an answer for, and when i do get something new, i relish it as a treat and an opportunity to learn something new.
just the other day i had a patient had a strain of H1N1. no big deal, right? yeah, except it was summer. and it was a strain from 2010. what?!?!?! seriously. and she was young. 40's right, not in the greatest of health, a few comorbidities, but nothing that would make me think, yeah, this one's a goner. so, of course, i took care of the patient for a coupla days, on BiPAP, without precautions. always seems to happen, right? then, oh yeah, H1N1 guys, make you sure you do precautions. thanks. gal keeps getting worse, buys a tube, and eventually a rotoprone bed. some serious Star Trekian stuff. no dice, dead with a week. weird. never saw that coming.

For Shame

i am a dood nurse. most nurses are females still, and have been for some time.

the recent influx of males into the profession of nursing may be a good thing. on the one hand, having more males in the profession is probably doing more to elevate nursing in status from being doctors handmaidens to, you know, an actual profession.

pro

case in point. our manager decided to try out a new thing. something about having the charge nurses introduce themselves to the patients every shift, or some such nonsense like that.

anyway, my manager is not the best communicator. he's this sooper non-confrontational guy, for one thing, and he's super old and kinda close to retiring. but, he has forgotten more about nursing than most of us will ever know, and he's sorta considered a saint around my hospital. for instance, he got grandfathered in and didn't have to get a BSN. like i said, he's an absolute saint.

so. with his new have-the-charge-nurses-introduce-themselves thing only sort of officially rolled out, chaos ensued. some charge nurses were like, so, are we supposed to do this every shift? and other nurses were super gung-ho about it, charging in and whatever.

now, i know that there are some hospital and floors that do this sort of thing already. the mom-baby floor were we delivered our kiddle-diddles did this, for example. it was perfect, the charge nurse came in, introduced herself in a non-threatening way, said she would be available, blah blah blah.

in an ICU, it is a little different. okay, it's really different. mom-baby, healthy people (mostly) having babies, flowers and sunshine and puppies and rainbows coming outta orifices and whatever.

ICU, hover between life and death.

so, when our sainted fearless leader didn't provide a script or guideline or anything for the charge nurses, many things were said. sometimes, what the charge nurses said caused the patients families to ask and wonder, 'why are you checking up on my nurse? is there something wrong? and then gung-ho charge nurse would have to back-track.

what needed to happen was a script needed to have been provided that took into consideration what patient families might think, and say things in a way that, oh whatever. it needed to have been done better.

one of charge nurses got asked by a patient for some dilaudid, and the charge nurse was all like, sure, i'll get right on that. the she sailed out of the room. well, turns out the dilaudid was discontinued, and the primary RN was left to pick of the pieces.

a lot of other stuff happened too, and most of it involved female charge nurse and female nursing staff. there were a lot of hurt feelings, and nobody said anything to Female Gung-Ho Charge Nurse. there was a lot of back talking and gossip though.

everytime somebody mentioned this, i always asked, okay, who is going to fix this? who is going to approach Female Gung-Ho Charge nurse? now, this may be stereotypical, but, this chatty bunch of women did nothing.

we have only two male charge nurses. and one of them did the gung-ho thing once, and he happened to do it a patient that was assigned to a male nurse that was friend of his.

scene 1: male charge nurse in the room, speaking with family and patient.

primary nurse walks in. 'whats going on?'

charge nurse, 'oh, you know, checking up on you. it's okay, the family says you're doing a good job.'

scene 2: right outside the room, right after scene 1, charge nurse and primary nurse.

primary nurse, 'what the HELL do you think you're doing in there, calling MY nursing into question with that family?'

(heating discussion follows, almost coming to physical blows, by some reports.)

and those two were friends!

afterwards, the to made up and it never happened again.

see, if i was being stereotypical, this would be the breakdown: female offends females, there is no confrontation, stuff gets dragged on, blah. dood offends dood, they immediately hash it out, problem solved, problem over.

okay, nuff of that. here's the con.

scene: an ICU, a LARGE female patient on a rotobed.

male ICU nurse (in a room full of other male nurses), 'okay, everybody grab something, and lets get this patient scooted up in bed. oh hey, be careful of her gunt.'

nurse j, ' whats a gunt?'

male ICU nurse, ' you know man, not quite a gut, not quite a ........'

nurse j, 'oh okay, i get it.'

awesome. 'gunt,' huh?

for shame. the darker side of male nursing.

Do you Speak Penis?

i wrote a while ago about my co-worker friend who has a way, shall we say, with catheters, in The Penis Whisperer.

i had a chance to put in a catheter with a urologist. it was pretty funny. i told him about my coworker. the urologist said he wasn't so much a whisperer as much as a 'penis shouter.' it was pretty funny.

Compliance

this happens all too often.......

Obit Backtrack

when my wife and i first got married, 6-ish years ago, she did something that sorta bugged me. when we got the sunday newspaper, or any paper for that matter, she would read the comics.....and the obituaries. i thought that was kinda weird, and i asked her about it. she said that all nurses read the obituaries. i though okay, whatever. this was well before i had any plans or aspirations of becoming a nurse myself.

then we decided that i should go to nursing school as well. i got a job at my wife's same hospital working as a nurse's aide. and guess what? all the nurses there would read the obituaries.

i would shake my head in disgust. for some reason, that just seemed wrong to me. something about that sort of morbid curiosity that rubbed me the wrong way. i could not the justify the interest in the dead.

now i understand. i've been a nurse now for a little over a year, and guess what? now i too read the obituaries. i had my first patient appear in one, and our hospital got a brief mention in the thanks section of my (former) patient's tribute.

it's so weird, i never thought i'd be an obit reader, and now here i am.

Rapport, Rock, Hard Place, and the NFL playoffs.

–noun

relation; connection, esp. harmonious or sympathetic relation: a teacher trying to establish close rapport with students.

from dictionary.reference.com.

i had a patient who was gonna die. in a sense, all of my patients are going to die, but with a terminal illness, sometimes you know someone is going to die sooner rather than later. the patient was in a bad way. young (40's) and terminal. they had a form of cancer that had spread throughout the body, and the only treatment was one that would be really, really bad for certain organs. said organs belonging to my patient were not working, and had not been working for some time.

i had an instructor in nursing skool tell me that all medicines were poison. i still think of them that way. i mean, look at all the commercials for meds on TV. the majority of the time, they have time to state the name of the drug, what it might help with, then the remainder of the time left, they pay those used car sales guys to go thru, like, 50 bazillion side effects.

'depressed? try abilify! side effects may include, increasedriskofsuicidedepressionanxietydecreasedlibidosexualfunctioningdeathorworse.

so my patient had this cancer, and these crappy organs, and had apparently been using home/herbal remedies to try and fix said organs. the ROCK; the patient had cancer. a treatable cancer, but the treatment wrecks havoc on certain organs which THE HARD PLACE were in failure, necessitating a transplant. the patient really needed an organ transplant, but with the cancer, there was no way.

you get the picture? terminal.

so, i'm work a buncha days in a row, then i have a buncha days off. so i had there patient for a long time at night, while during the days, there were different nurses that came and went. most of the day nurses would report to me that the patient was in a sooper funk, and either depressed or in denial or inappropriately processing, if at all, the fact that DEATH was in the room.

however, the patient was totally 'with it.' for me.

why?

well, for one thing, i didn't talk to the patient about dying. didn't mention it. instead, i talked about stuff like college and pro football, favorite books i read/was reading. i spoke about my family. i asked about my patient's family. and really got to know about my patient and the life that was BEFORE.

where dayshift got one-word answers or no answers at all, i got life stories. i didn't walk into the room with a sympathetic look on my face and encourage my patient to 'just let it all out,' or 'give a good cry.' i refused to look in the corner of the room where DEATH was sitting, reading his copy of People magazine.

lest you think i'm some sort of genius or something for my approach, let me tell you why i did what i did. i am not good with emotions. i'm not a fan of how my emotions make me feel. plus, the mechanism that enables most humans to cry broke on me a long time ago and i never took it back in to get it fixed. when i cry, it sounds like hell and looks worse. snot, redness, weird noises and the works. NOT. PRETTY.

so i do not allow my self to get emotional. not for my self or for my patients. i don't want to cry, and i don't want my patients to cry either. that is not to say that i don't feel for my patients, i feel very deeply for them, just not while i'm at work. i save that feeling crap for my days off the occasional bottle of Blue Moon.

so DEATH is in the room. sitting at the bedside, in his dark rotting robes, playing 'angry birds' on his ipad, like everybody else. he's probably pissed that i'm ignoring him, or maybe not. i figure he's seen everything at this point. point is, i ignore him. and for twelve hours that is my shift, my patient can ignore him too. because i am babbling about Malcolm Gladwell and Brett Fav-ruh, and the Miracle at Qwest field. and my wife'd boob-feeding and how max drives me crazy.

and it is just what my patient needed. (disclaimer; i do offer to hold my patients hands, if needed and appropriate. i do practice appropriate therapeutic touch. and i touch my patients without gloves. at least a couple times per shift.)

Frustration & Delight

from Conversations with a 3.5 year old.

nurse j; 'please put your shoes on.'

max; 'put my shoes on?'

nurse j; 'yes. the brown shoes.'

max; 'these shoes?'

'no, the brown ones. the ones right in front of you.'

'these ones?'

'no, the other ones.'

'these ones?'

'no.'

'these ones?'

'no"

'these ones?' (as maximus continues to grab EVERY SINGLE PAIR OF SHOES HE OWNS, WITH THE EXCEPTION OF THE ONES I WANT HIM TO WEAR, WHICH ARE NEAREST TO HIM AND RIGHT IN FRONT OF HIM).

there is much internal cursing, nurse j head explodes.

*************************************************************************************

max; 'where we going?'

nurse j; 'to pick up mama from the dentist.'

max; 'to pick up mama?'

nurse j; 'yes.'

'from the dentist?'

'yes.'

we pick up the action in our story...............2 seconds later.

'we going to pick up mama?'

'yes.'

'from the dentist?'

'yes.'

2 seconds later.

'where's mama?'

cursing, head explodes.

************************************************************************************

just writing this down brings back that familiar, when-is-my-head-gonna explode feeling that i had when the conversations first took place. or when many similar conversations like these take place every day. the poor kid just wants to talk and be a part of the action, he just doesn't have the vocabulary to maintain a conversation longer that 15 seconds that doesn't center around Toy Story Free or Cars.

i wonder what an ART line would show my pressure was during those moments.

or this one, which probably happens just often enough to keep my head from ackshually exploding.

max; 'dadda...'

nurse j; 'yes, max.'

max; 'i love you.'

nurse j; 'thank you max, i love you too.'

'dadda, we best friends?'

'yes max, we're best friends.'

'i love you dadda. sing-you are my shunshine. gotta singy song to me, sing shunshine. okay, dadda?'

'okay max. you are my sunshine, my only sunshine............'

Exasperation

i remember conversations my father and mother would have that would drive my dad NUTS. he would ask a question of my mother and she would answer him in such a way i could ackshully see my dad's head hurting.

i used to laugh. it was funny.

one time my mom was trying to call our neighbors, but she kept dialing our number, which kept ringing back busy. finally, (we were sitting at the table eating dinner) when she told us what number she was dialing, and we told her that was OUR number, she burst out with, "why don't you answer when i called ME?!?!?"

it was hilarious.

back then.

now, i am married.

yeah, you know what's coming.

The other day i'm in super clean mode. putting away christmas, making trips to the storage garage we share with our friends, doing laundry, cleaning, etcetera.

I'm about to do a garbage run, so i ask my wife (who's breastfeeeding Brutus at the time-hey, maybe that's it-any chance she'e leaking brain cells in her boob milk? do they grow back? easy people, i just want my usually-smarter-than-me, more common-sense-than-me wife back) if the garbages need to be emptied.

it was a simple query. "are the garbages in the bathrooms empty?"

two things to consider; 1) the garbage bags in the bathrooms, 2) are they empty. question mark.

i was looking for either a yes (meaning the wifey had already emptied them, a distinct possibility, since i was already looking at several plastic garbage bags full of stuff), or a no, meaning the garbages in the bathrooms were still full.

yes (go empty the garbages) or no (already done).

what i got was, 'yes, they need to be emptied.'

i had instant brain freeze and flashback to all those times i'd laughed at my old man slowly being driven to drink/insane by my moms crazy answers.

so, do women go to school to learn how to do this, is it passed on from generation to generation, is it genetic or what?

Worst Patient Olympics

candidate #2

the end of the year means a lot of things to different people. to some, it means you eat a lot. to others, it's all about family.

to people who have met their health insurance deductible, it can mean only one thing-free surgery!!

the end of the year is surprisingly busy for certain kinds of docs, docs that do things that may be considered 'elective surgeries.' like getting that knee that's been bothering you some time looked at, or that pesky hernia you've had ever since you helped your uncle charlie switch out his big old tube TV for the new plasma, or even that funny growth you've had on the side of your neck removed.

so you've met your deductible. that means free surgery. THAT much you do know. you don't know much about medicine or anything like that, that's for the nerds you made fun of in high school (those nerds, coincidentally, are now your doctors and accountants and engineers-imagine that!). one thing those nerds with soft hands do worry about is what kinds of meds you use. now, you did have those stents placed in you heart in April (eat vegetables? more fiber? what do i look like, a rabbit? i'm a MAN, and i eat whatever the damn heck i feel like, and that means MEAT and POTATOES), and so you've been on blood thinners since then.

whatever. if being on that dang blood-thinner means i can't have my surgery now, while it's free, then i'll just stop taking it. or i'll tell him that i stopped a while ago. yeah, sounds like a plan.

so my patient blatantly lied to his surgeon about being on a potent blood thinner, or anti platelet aggregator. think plavix, only better and more badass. i did some research on the drug, and it turns out it is undetectable in plasma, which may explain why this guys presurgery labs turned out okay. also, it is a competitive inhibitor, which means that the only way to get rid of the stuff is to bleed it out. the website recommends stopping effient at least 7 days prior to any planned surgery. seven. not 2, or three, but seven. SEVEN.

did my patient lie about being on the drug? yes. did he discontinue the drug 7 days prior? no. did he start to bleed like crazy on the capillary level were he got his non-essential, non-life threatening, elective surgery days before Christmas? yes. did he end up almost dying and having to have emergency surgery, get intubated, right before the holidaze? yup, yup, yuppers and sure did.

the things people do. seriously.

Worst Patient Olympics

candidate #1

as i walk into the room to assess my just-got-her-knee-fixed lady;

"hi, my husband is an attorney, and he loves to sue people like you. so.......have you done anything wrong i could sue you for?"

the look on her face said she wasn't kidding. not one little bit.

Speaking of Endo......

this was posted outside the employees entrance to our outpatient endoscopy department (the people that are in charge of sticking cameras and scopes where the sun don't shine.) i thought it was funny.

ANYONE IN NEED OF AN

ORIFICE PROBING HERE

IN ENDOSCOPY:

PLEASE CHECK IN

THROUGH OUR FRONT

ENTRANCE.

WE ARE THE ONLY ONES

WHO GET TO USE THE

BACK DOOR.

THANK YOU!

Ready, Set,.......GI BLEED!

in case you've been living under a rock for the last few years or so, vampires are back in popular demand.
and there sure seem to be no sexier creatures than a voluptuous blood-sucking babe vampiressess.

personally, i'm all about Team Alice, presented here, for your viewing pleasure.

(this is Ashley Greene, the actress who portrays Alice in the Twilight series)

..........and we're back.

which leads me to this question; do vampires poop like GI bleeders do?

ha ha, ha, ho, oh boy, that was a good one nurse j, you're SO funny!

mokay, well, at least i think i'm funny.

see, the hooman GI (gastrointestinal, or gut) system is not designed to consume blood, specially not your own.

so, the other night, i had a GI bleeder.

there are several things that suck about GI bleeds.

first, the poop smells turrrrrrrible. not that poop generally smells good to begin with under the best of circumstances, but trust me, this is worse. if the bleed is above the small intestine, like in your esophagus or stomach, you will have dark tar like poop. and probably coffee ground barf. if it is in your lower interstines, or your large intestine, the poop-blood with still be horrible, just more parts blood than bloody poop. in either case, it smells. bad.

possible worse than the smell is the preparation. if it is a lower GI scope (insert scope into anus, have a look around), the patient gets to drink a gallon (4000 mls) of a delightful concoction called GoLYTELY. it is called this probably because it is full of electrolytes to help replace what you're gonna lose, since the other wonderful thing that GoLYTELY does is clean. you. out.

literally. we have to make you drink this stuff till you are pooping straight water out your behind.

'when the poop runs clear, bring that scope near.'

if you are unlucky enough to have a patient that is bed bound, you are looking at a night filled with multiple linen changes, because your patient is going to POOP. HIS. SMELLY. GUTS. OUT.

you should also be prepared for the awesome poop-running-off-of-the-bed-scenario.

if you have a patient that can walk, or sorta walk, then you are in for the 5 second 5 yard dash Olympics.

luckily, my GI bleeder was a walker. sort of. he was not a sexy female vampiressess though. i asked. maybe, under that old man exterior.....but no. just a legit old man bleeder.

anyways, over the course of the night, i sprinted to his room every time the call light rang. i had it down to a science. we had ditched the SCD's after the first run, and moved the bed closer to the crapper.

call lights rings, and i'm off. run into the room, pulling gloves on as i round the corner. he's already taking off the blood pressure cuff, and then i sleep the monitor, tear the blankets off, disconnect the leads and sat monitor, make sure the IV line was clear, then shuffle shuffle shuffle.

then, while he fills the room and the hall with the smell of freshly baked bread (i wish), i would change his chux and or his sheets, depending on how badly he leaked, as well as wipe up the floor.

then i would vacate the room for a few minutes to breathe, uh, i mean give him some privacy.

when he would ring again, i'd help him back into bed, make him drink more stuff, and then wait to do it all over again.

on the bright side, the more often he pooped, the less bad the smell was. either that or i was getting used to the smell and was that much closer to being dead inside.

ten trips. 1st poop; bloody hell!! 10th poop; clear. mission accomplished!

i hope they were able to fix what ever it was of his that was bleeding inside.

Precautions

i got a call one night from the son of one of my patients. the dood was calling to ask 'what bug is it that dad has?' and we proceeded to have an interesting conversation.......

nurse j, 'clostridium difficile.'

Mr Oblivious, 'is there something easier i can tell the doctor? my son, the one who was visiting his grandpa yesterday, well, he's got real bad diarrhea and vomiting now. we were wondering if maybe he picked up whatever it is that his grandpa has......we're thinking we might have to take him to his pediatrician.'

nurse j, 'well, we call it 'C-diff' for short........how old is the kid?'

Mr Oblivious, 'my son is four. he was, you know, acting like a four year old, crawling around the room and stuff. you know how four year olds can be.'

nurse j, *head suddenly hurting in exasperation* 'yeah, i sure do.'

Mr Oblivious, 'so, it it real bad? this cliff diff thing?'

nurse j, 'well, we have natural bacteria, 'good bacteria,' if you will, in our gut already, including this c-diff, or clostridium difficile. when we put you on antibiotics, the antibiotics don't discriminate between the bad bacteria that is causing your dad's pneumonia and the good bacteria in your gut. so the 'good bacteria' gets killed off, and that give the c-diff an opportunity to take over. that is why your dad also has this slimy mucousy diarrhea. so then we usually have to start yet another antibiotic to combat the c-diff. is any of this making sense.'

Mr Oblivious, 'uh, yeah kinda. so it's bad? i mean, we go in there all the time, and hold his hand and stuff. and we wash our hands too, most of the time after we leave. but, you know, not really good, like 60 seconds and stuff, or use hot water. should we be using gloves or something?'

nurse j, *huge sigh* plus silent *facepalm* 'um yeah, that's why we have a notice on the door that has 'CONTACT PRECAUTIONS' on it, as well as that cart with gloves and disposable gowns in it for visitors and staff to wear........have you seen the cart and the sign?'

Mr Oblivious, 'ha, oh yeah, we pass right by that cart all the time. i guess we should be using it, huh?'

nurse j, 'yeah, that might be something to think about.'

ps, our floor has a no one under 11 years old policy, and this visit did NOT occur on my shift. musta happened on day shift or something. sheesh man.

Sacred Moments

the holidaze are interesting times to work in healthcare. all the people with seniority are at home, and as far as scheduled things, doc's try to avoid doing elective stuff right beforehand so they don't have to round on peeps/get called during this special time.

so the patient population is those peeps that are REALLY sick, and you generally have skeleton/rookie/newer/less experienced people taking care of them.

i have been a nurse for a little over a year, and i work on a floor with a wealth of experience, so yeah, i worked a lot of holidaze.

on one of those holidaze, i had a patient die. i don't want to say that i 'lost' him, rather, i 'let him go.'

basically, the dood had been stringing lights (at 96!) had found a nest of bugs (some of which he may have been allergic to-) done the 'i-found-bugs-i'm-allergic-to' dance, while still on the ladder, and down goes frazier.

he was lucky he only broke a coupla ribs, his hip and humerus. unfortunately, at that advanced age, it usually only takes one little thing like that to push people over the edge, and in the end, it was the pneumonia that did him in. 96 years old, frequent, productive, ineffective cough. NOT clearing his own secretions. cause of death could have been listed as 'booger.'

he was DNR (do not resuscitate) NCR (no cardiac resuscitation, meaning no cardiac stuff, like cardioversion or cardiac drips), as well as DNI (do not intubate). thank the good Lord for that.

within the bounds of these limitations, because of course being code status DNR, DNI, and NCR does not mean 'do not treat,' we were doing everything else we could for him. antibiotics, frequent suctioning, BiPAP.

he mucus plugged the night before Thanksgiving eve. i noticed his O2 saturation line was going squirrelly on me, so i walked into his room to check it's position, thinking maybe it has slipped off of his finger. normally, this guys had rales and rhonchi (unnatural noises your lungs make when there is stuff in them that shouldn't be, like lotso' boogers) so loud that you could hear them without a stethoscope just walking into the room.

when i walked in, there was silence. the only sound was of the BiPAP, trying ineffectually to push air into this guys lungs. that meant that he had mucus plugged, or gotten boogers so backed up in his lungs that it had occluded his airway, hence the inability to 'move air,' hence the silence. he was still alert, and was in fact waving his arms around and still had good color.

i like working my particular weekend in part because matching my 6-in-a-row shifts is the worlds best RT, or respiratory therapist. if you need an ART line, a ABG, a stat intubation, this is your man. Bartholomew is the MAN. anyways, i called him, and between the nursing team and him, we pulled the guy back. at one point, the color on this dood was so bad, he could have been the fourth member of the blue man group. but we got him back, he was alert and oriented and back to where he was before.

almost.

during this ....... event, things had gotten so hairy i wasn't sure if he was gonna pull out, so i had asked our charge nurse to notify family. if the hospital is calling you at 4 in th AM, it is hardly ever a good thing.

a coupla of the kids had shown up by the time we'd pulled old dad thru, and so i explained to them what had happened and what we'd done and basically told them that it would probably happen again, and that there was no way to know when it would happen, and that one of those times, we would probably loose him.

before he mucus plugged that first time, he was the chipperiest 96 year old you ever met. man, he was WITH it. all into college basketball and the foosball and everything.

after the first mucus plug, he just slept a lot.

by midnight on Thanksgiving, when he mucus plugged for the fourth time in 20 hours, we were pulling up more than just sticky yellow boogers. we were getting blood back as well, and we couldn't get the offending plug free. the family came again, and once we pulled all ventilation support, he only lasted 10 minutes. just long enough to tell his family he loved them, and it was time for him to sleep.

i imagine that there have got to be no better words to hear from a dying parent. the love part is self-explanatory, but the key is the 'i'm ready to go.' i feel like it absolves the children of any feelings of responsibility for allowing death to take it's natural course. and i admire the bravery, courage and self restraint the kids displayed in honoring their dad's wishes. the difficult thing in those circumstances is that at any time, any of the kids could have changed course and asked or demanded intubation, cardioversion or reversal of any of the parameters i mentioned earlier. they did not, and the Death came as peacefully as it could have, under those circumstances.

in those final moments, i administered some comfort measure doses of ativan and morphine, and left them to be with their dad alone.

what do you do when your dad dies on a holiday? how many holidays does it take before it does't kill you when people talk about it?

anyways, i got to be in the room again while somebody passed thru to the other side.

sometimes i wish i still remembered how to cry.

Nurse K! The Triumphant Return!

Go read my biggest inspiration! Tell her I sent you!! Nurse K!

Full Moon

'bad things happen in hospitals when there is a full moon. '

i'd heard this before, and always pooh-poohed it as a stupid superstition. like the one that a nursing school instructor told me about. she said that when she had a patient that was going south, she would tie a knot in the patients bedsheet, and swore up and down that it kept patients alive.

baloney.

then, i had a full moon night.

1900 hours.

first of all, the ER was nuts. that seems to be the first prerequisite for a truly crayzee full moon night. eventually, they went on divert, at around 2 in the morning.

before that, we had been triaging people like crayzee. the neuro/shock/trauma/cardiovascular intensive care units were full, so that left us as the the last stand for new/crashing admits. yay.

2300 hours.

triaging means that you look at the patients on your floor and decide who is MOST stable. we move people to less acute floors that maybe would have been going there anyways the next day......and so forth. so, you make a hard decision, ship somebody out, and prepare to get a crashing patient. not fun.

of course, thru our charge nurse, we hear the scuttle-butt from the rest of the hospital that this patient is going to this floor or that floor. we watch the ER board like hawks, waiting to see where the chips would fall. we had, like three codes blues and a couple of rapid responses.

0000 hours.

one of those code blues needed one of our rooms, and while we were busy triaging, they had to bag the entire time, until our room became available.

good times all around.

0200 hours.

there was also a storm, and so, of course, the power goes out. just as we're stabilizing the crashing patient that we just admitted.

nice.

darkness for a few seconds, then auxiliary power comes on......and we're back. we have these green, glow-in-dark outlets that are the designated outlets for these situations. problem is, we don't really have enough outlets to go around for all the equipment AND the computers. so not only do most of the computers in the rooms not work, neither do most of the computers in the nurses station.

well, the power will come back on later, we'll chart stuff then.

0245 hours.

hey, nurse J, looks like we need to triage another patient. somebody in the ER needs it so........ lets move 29.

okay.

the patient in 29 is a recovering abdominal surgery, stable as anything, totally on the mend, on the way out for sure. mid fifties, newly retired, looking forward to an impeding grandson. pt spouse, on the way out early that night had jokingly admonished me to,"keep my sweetie alive, nurse j, i'm too young to be alone." smile and nod, "of course i will."

right?

0300 hours.

walk into the room right behind the respiratory therapist, who got the same news i did and is in there to get the CPAP ready for transfer.

i glance at the monitor. sinus rhythm, sats in the.....90? well, the waveform looks like crap, no wonder. i grab the sat monitor to see if it on the patients finger correctly and yeah, it's on there good. hmmmm...........

89.........88........87..........

0301 hours.

uh oh, where's my pulse? (feeling for a pulse, patients is still warm in the legs and feet)

can't find a pulse.

0301 hours 30 seconds.

i see the charge nurse walking past my room, hey, man we're not gonna be able to transfer this patient, we're gonna code'em in second.

charge nurse, great. we better call it overhead.

0301 hours 45 seconds.

help arrives.

i'm trying to find a pulse and getting ready to start CPR when another nurse walks in to help.

uh-oh, what's going on with the QRS? quick glance at the monitor from me reveals that i've lost the nice even sinus rhythm i had going, and my QRS's were now getting really really wide.

shit.

0302 hours.

start CPR. begin nightmare dream sequence.

0302 hours thru 0320 hours;

attempt to intubate. pt vomits on most people within a three foot radius. intubate. can't get labs up or a history because the computers in the room aren't working because the power is still out. draw stat labs (100% WNL-within normal limits-100%). continue CPR, with pauses to see if we can ever get a pulse. no joy. try to answer the questions of the cardiologist, the hospitalist, three residents, and a pulmonologist (who was the gal that ordered the pt be transfered in the first place.)

no, nothing is wrong with the labs, everything was normal. crit, electrolytes, lactate ..... everything. afebrile, alert and oriented, vital signs stable.

WITHIN NORMAL LIMITS.

0319 hours.

cardiologist, 'does anyone here object to ending this now? anything we missed?'

silence. except for the rhythmic beat of the CPR, and the whoosh from the person bagging my patient, no one objects.

0321 hours. call off the code. TOD (time of death) 0320 hours.

0322. start cleaning up the patient. is it an ME (medical examiner) case? nope.

okay. remove lines, tubes, drains, leads, patches. clean up vomit, poop and blood. change the sheets. throw stuff away.

deodorize the room, throw away the garbages.

hide the evidence of my failure and my broken promise.

0340 hours.

patient spouse arrives from motel down the street. it took a while to get to the hospital, what with the storm and the power outage and having to get dressed by the light of your cell phone, but the spouse is here now, sitting in a chair outside the room, speaking with the doctor.

i'm sorry, but there was nothing more that we could do. we did everything we could. i'm sorry for your loss.

0345 hours.

room is clean. spouse is at the bedside, holding hands with the deceased. i close the door and leave to go sit at the nurses station. the cameras still have power, i promise the doctor that i will keep an eye on the spouse, because she "doesn't need another patient tonight."

0400 hours, accompany spouse to the parking lot, in a light drizzle. find the car.

are you gonna be okay?

yeah. i think. i'm not sure. pause.......i'm not ready to be alone.

0630 hours.

mercifull the shift is over. as i pull into my driveway, i happen to look up and see that, nice, tonight was a full moon.

damn you, stupid moon. and my disbelief about nursing superstitions. that's what i get for dissing the karmic gods of nursing, they piss buckets of horribleness out on me.

shoulda tied a knot in that patient's bedsheet.