Change of shift

I'm in my first change of shift!!! I wanted to thank Braden for inviting me to participate and for using my story.

When I first started blogging I had no idea that it was such a social network. In the few months that I have been blogging I have had a great time reading other's blogs and getting a sense of what it is like out there for other nurses. I have also enjoyed writing down some of my cherished memories and also getting some stress off my chest!! It has been good for me. I'm looking forward to continuing on and I want to thank everyone that has read my blog and especially to those that have commented to me.

Check out the latest edition of change of shift here. And be sure to click on my story!!

I also wanted to welcome Kaitlyn (AKA Katie) from this post on my blog to the blogging world. She did a beautiful first post on how she feels about the start of her career and I'm so glad she took my advice and started a blog of her own. I only wish I had started one at the beginning of my career so that I would have all the memories that she will end up with written down.

So, WELCOME Kaitlyn!!

My tax dollars hard at work

Tonight I took care of this patient who has been in my hospital since April 9th. He originally came in with a medication reaction and was intubated. He was trached and then de-trached. His kidneys failed at some point so he is on dialysis now. He was in ICU for quite awhile and then transferred out to a regular medical floor. Complains of chest pain for a few days and then has some questionable EKG changes so buys himself a bed in the CCU. Has a negative MIBI stress so I transfer him back to the medical floor.

Are you wondering where my tax dollars come into play?

He is an illegal alien from a S. American country. So, he doesn't work and has no insurance. No outpatient dialysis center will take him due to no insurance so he has to remain hospitalized. Apparently we cannot discharge a patient who has no outpatient dialysis set up. So instead he drains tax money by being hospitalized for 2 1/2 months only so he can have dialysis 3x a week.

I have no issues with someone not having insurance. I recently took care of another young man in his 30's who underwent 2 angioplasties in about a week's time (long story involving med noncompliance) who had no insurance. He also racked up a big bill but at least he works. He talked with a social worker and is applying for state insurance etc and will work out a payment plan with the hospital. He'll be paying for a long time but at least he'll pay.

We will see nothing, not one penny from this guy. I also have no problem with the fact that he got some medical care. Sure, we are the melting pot etc but he's getting care at tax payer expense (and his bill must be in the millions at this point) when other American citizens are scared to come to the doctor at all due to the cost of their copays. It's a sad situation that our healthcare system is in.

Oh and the other thing I wonder about.............why did we only stress test him and not just do a cardiac cath. I mean come on....aren't stress tests more inaccurate than caths? We already have the million dollar work up so why not just do it right??????

And for those of you that are shaking your heads at me right now thinking I'm horrible to be saying all this I have something for you to think about. If you or I moved to his S. American country and lived there illegally and didn't work or worked under the table and got this sick............would that country take care of us like we have taken care of this man? I seriously doubt it.

WWJD?

Do you ever get those patients or families that just won't leave you or your unit alone after they go?  We had one recently.  I'm all for patients & families telling us that we did a good job and saying thanks.......heck it makes me feel good when MY name specifically is on the card.

We had this patient recently that I'll call Harry.  He originally came in with cellulitis of his leg.  But being obese, diabetic and waiting a few too many days to come in didn't fare well for him.  Within 2-3 days of admission he was in full blown septic shock.....intubated and on 3 pressors.  It was touch and go for at least a week with him.  

He had a lovely wife we initially thought, though somewhat strange.  Then we found out why.  She is a born again Christian.  Now, don't anyone take offense here.  I'm a practicing Episcopal and go to church as often as my working schedule allows.  My kids just finished another year of Sunday School.  We say our prayers, repent, fast at Lent, and recite the Nicene Creed.  We are a God loving family.  I have even been known to share scripture on friend's caringbridge sites that are for their chronically sick children.

Now that we've gotten that straight let's get back to Harry's wife.   She would stay at his bedside all day which was wonderful for him.  But then she would go home and immediately call and ask us to pray WITH her for him.  Instead we would put the phone up to his ear and she seriously would pray for hours (2-3) over the phone to him from home.  We went about our nursing duties while she did this.

Long story short.......after many antibiotics and a trach Harry pulled through and got to go home.  I AM sure that the prayer had some role in it.  However, now she calls on a weekly basis to talk to her favorite nurses.  She weekly sends her favorite nurses and docs prayer books etc.  She just cannot shove Jesus far enough into your face.  I always thought religion was kind of like politics and that you were supposed to keep it to yourself or at least find out if the other person wants to talk about your views.

Her most recent mailing was for this Christian camp/retreat that she would like her favorite 3 to go to with her and Harry.  She's even willing to pay their way if they will come and keep an eye on him while they are there!!  Yikes woman, let it go!!

My daughter will be having major surgery in a little under a month.  I'm just starting to wonder what I should do for the nurses to thank them.  Hmmmmmm..........maybe some cookies, chocolates, or just a nice thank you note with the names of the ones who took care of her.  What do you guys think?

Being the good Episcopal that I am though, I will be saying a prayer for her before the surgery starts.

Bringing back memories

Every year my hospital hires what they call clinical partners. They are nursing students that will be entering their senior year in their nursing program in the fall. They are hired for the summer to shadow a nurse on each unit usually for either the day or evening shift. It's a good program though we have recently gotten some interesting CP's on our unit.

This year we have Katie (name changed for privacy). She's doing great and is a real go getter. She is always asking questions and seems to want to learn. She knows about the job I'm going to be going to soon so she picks my brain often. She's good for the ego too!!!

The last shift I worked with her brought back quite a few memories for me. We had a DNR patient who had been in the hospital for a month pass away with all his family at his side. This was her first real and family grieving death and her first time seeing a dead body.

This brought me back to my first death and dead body. My first death was also a DNR thankfully. I was still on the med/surg/onco floor then and it was an older gentleman that had cancer and had been with us for a bit over a month. I had my 8 patient assignment and had started with the sickest and was making my way forward. One of my coworkers came up to me and asked if the patient in room 10 was expected to die. I hadn't been told he was so I was kinda freaked out by it all. I had been involved in a code before but this was MY patient. The code was right before change of shift and she didn't make it but I was going home so I wasn't involved in her post-mortum care at all. I distinctly remember walking into my patient's room and seeing his dead body and feeling kinda strange. Like I didn't belong there. And then with post-mortum care like I was violating him even though his spirit had already left. Over time I have gotten used to handling death and dead bodies but I remember that first one like it was yesterday.

I asked Katie as she was helping us do the PM care if it was her first dead body and she got all quiet and said it was. Welcome to the club sweetie. You have had your induction and it goes on from here.

Before PM care was even finished on this man they call an angioplasty code overhead. Being fresh and new Katie gets all excited and says she went on one the other day but it didn't turn out to be someone needing angioplasty so she didn't really get to see anything good. So, I take her to the ED in hopes this is the real thing. It was and she got to experience it from ED to cath lab to CCU. What a neat experience for her.

Again, this brings back memories, mostly from nursing school of getting to do the "whole" process in patient care. Seeing beginning to end and being satisfied that the patient got the care they needed. Kind of a cool experince and one that we more seasoned nurses don't get to experience anymore.

The lovely call light system we have

Our call light system is horrible. They have been telling us for years that we will be getting a new one. Even had several vendors in for us to help pick a new one. But here we are still stuck with this stinking executone.

Almost every shift I work it goes off for service. And when I say it goes off I mean it beeps incessantly. Did I say incessantly? INCESSANTLY. We beep engineering and they say they are working on it and an hour later guess what......................IT'S STILL BEEPING. AHHHHHHHH.

I have little tolerance for noises (surprising that I would work in a critical care unit with monitors huh!!) and tonite we were very busy and sure enough beep, Beep, BEep, BEEp, BEEP goes the executone.

I THINK I MAY GO HOMICIDAL SOON..................or at the very least to the insane asylum.

Code what????

I was perusing some other nursing blogs late last night as I couldn't sleep (ahh the joys of working nights and trying to have a normal family life on your nights off) and ran into this post by Braden over at 20 out of 10 regarding all the types of code calls they have there.  Laughing hysterically I thought to myself "hey, self, we have the same thing!!"  Though my hospital has gotten away from calling them all code this and code that.  We now just have initials called overhead too.

Here are a sampling of the ones we have:

Code 8 (the regular code blue in most places but like Braden said named after a number so as not to scare the patients)

Code Mr. Green (severely agitated patient or visitor)

Code PCI (primary angioplasty)

Code Adam (lost or kidnapped pedi patient)

Code Orange (I think this is a bomb threat)

Code 123 Red (fire)

I think that's it for the actual "codes".  Now to move on to the initials:

MET called overheard along with the floor and room # means medical emergency team or rapid response team in some places

BAT called again along with the floor means the acute stroke team

Ok I think that's it on the alpha-numeric soup!!

Updated:

I checked the back of my badge after I got to work and not surprisingly I got a few of these wrong!!  The bomb threat is actually a Code Grey.  And I skipped one:  Code 911 (nope not the one where a patient is actually coding!!) which is an external disaster during which the phone tree should be activated to get as much staff as possible in the building.  This would be something like a major accident or chemical spill involving mass casualties etc.

Paperwork

I would love my job if it weren't for paperwork. Need I say more nurses???

Due to the litigious nature of our society we are always creating new paperwork. In fact, there is so much paperwork that says that you took care of the patient thoroughly that you hardly have time to actually take care of the patient. And one form is never enough either. We must have multiple forms to say the same thing over and over again. The hospital admin says that they are doing their best to eliminate double charting but then the next email from them is the introduction to....................you guessed it..............another new form.

So here it is 4am and as usual I'm just now getting to my paperwork. (Though I guess really I'm here blogging to avoid doing it for a few more minutes!!) All the while chanting silently to myself "I love my job, I love my job, I love my job......................." and feeling like this (just insert scrubs instead of the tie):

One complication after another

Remember the guy from two posts ago that was the "happy" guy from a sad one and a happy one? Well, things didn't go so well for him after that. He remained NSR but that's about all that went well for him.

The next morning he got up to go to the BR for a BM (I've come to hate BM's ya know!!) and passed out with bradycardia to asystole. After a minute of CPR he came back to and said he had quite the good feeling like an endorphin release. Luckily I was at home sleeping to miss all of it!!

Needless to say, this earned him a pacemaker once we had corrected his INR. So, I come in after 2 days off expecting to not see him there. Not only is he still here now with a pacer, but in the cath lab during the pacer insertion they nicked his lung and his post-pacer CXR showed a moderate to large pneumothorax..........uggh. What next?!?

I'll tell ya what. Being allergic to PCN they Rx'd vancomycin as his pacer antibiotic. Not long after his dose I go into his room to check on him (and he and his SO are so nice that I had been in and out practically all evening anyway) and he's red from the clavicles up..............WTF is going on now I ask myself. Could this actually be Red Man Syndrome? I have read about it but had never actually seen it. But then again, I tell myself, he's had practically every other complication.......RAFl, pauses, then intractable RAFl again, does ok with the TEE and cardioversion but then has asystole so what more could go right for this poor guy!!!!

So was it Red Man Syndrome? We aren't fully sure as no doc laid their beady eyes on him (one of the joys of a community hospital) but it certainly fit the symptoms of a mild case of it.

Oh and want to hear something funny..........I'm going to teach sex education with him to his 7th & 8th grade science class!!!! Yup, you read that right!! He teaches science to middle schoolers and his school nurse doesn't feel comfortable helping with the girls (WHAT???) so right now he teaches it co-ed but we've gotten along so well that he asked me if I'd be comfortable teaching it with him. Hey, why not. I'm always up for an adventure. How bad could it be???

Some nursing humor

I thought it was time for some humor so here goes...........

Letterman's Top 10 for reasons to become a nurse:

1) Pays better then fast food, though the hours aren't as good.
2) Fashionable shoes and sexy white uniforms.
3) Needles: "Tis better to give than receive"
4) Reassure your patients that all bleeding stops...eventually.
5) Expose yourself to rare, exciting and new diseases.
6) Interesting aromas.
7) Courteous and infallible doctors who always leave clear orders in perfectly legible handwriting.
8) Do enough charting to navigate around the world.
9) Celebrate all the holidays with your friends- at work.
10) Take comfort that most of your patients survive no matter what you do to them.

Pharmacy joke

A nice, calm and respectable lady went into the pharmacy, walked up to the pharmacist, looked straight into his eyes, and said, "I would like to buy some cyanide."

The pharmacist asked, "Why in the world do you need cyanide?"

The lady replied, "I need it to poison my husband."

The pharmacist's eyes got big and he exclaimed, "Lord have mercy! I can't give you cyanide to kill your husband. That's against the law! I'll lose my license! They'll throw both of us in jail! All kinds of bad things will happen.

Absolutely not! You CANNOT have any cyanide!"

The lady reached into her purse and pulled out a picture of her
husband in bed with the pharmacist's wife.

The pharmacist looked at the picture and replied, "Well now, that's
different. You didn't tell me you had a prescription."

YOU KNOW YOU'RE A NURSE IF...

1) the front of your scrubs reads

"Nurses... here to save your ass, not kiss it!"

2) you occasionally park in the space with the
"physicians only" sign... and knock it over.

3) you believe some patients are alive only because

it's illegal to kill them.

4) you recognize that you can't cure stupid.

5) you own at least three pens with the names of
prescription medications on them.

6) you believe there's a special place in hell for the
inventor of the call light.

7) you believe that saying "it can't get any worse"
causes it to get worse just to show you it can.

8) you wash your hands BEFORE you go to the bathroom.

9) you believe that any job where you can drive to work
in your pajamas is a cool one.

10) you consider a tongue depressor an eating utensil.

11) eating microwave popcorn out of a clean bedpan

is perfectly natural.

12) you've been exposed to so many x-rays that you
consider it a form of birth control.

13) you've ever heard a patient with a nose ring, a brow
ring, and twelve earrings say "I'm afraid of shots."

14) you've ever placed a bet
on someone's blood alcohol level.

15) you've told a confused patient that your name is

that of a coworker and to call if they need help.

16) your bladder can expand to the size of

a winnebago's water tank.

17) you have seen more penises than

any prostitute could dream of.

18) you believe that not all patients are annoying...
some are unconscious.

19) your family and friends refuse to watch

medical sitcoms with you because you spend

the whole time correcting everyone and

pointing out upside down x-rays.

20) you don't get excited about blood,

unless it's your own.

21) you've sworn to have "do not resuscitate"

tattooed on your chest. Soon.

22) discussing dismemberment over a gourmet meal
is perfectly normal to you.

23) your idea of fine dining is anywhere

you can sit down to eat.

24) your idea of a good time is a

cardiac arrest at shift change.

25) you believe in the aerial spraying of prozac.

26) you believe that "shallow gene pool"

should be a recognized diagnosis.

27) you believe that the government should

require permits to reproduce.

28) you believe that unspeakable evils will befall anyone
who utters the phrase "Wow, it's really quiet, isn't it?

29) you have ever wanted to write a book entitled
"Suicide: getting it right the first time."

30) you have ever had a patient look you straight in the
eye and say "I have no idea how that got stuck in there."

31) you've had to leave a patient's room

before you begin to laugh uncontrollably.

A sad one and a happy one

Remains orally intubated.  Unresponsive to noxious stimuli.  No pupillary response.  No gag or cough reflux.  Does not breathe over ventilator assisted respirations.  No spontaneous movements.  

This is how my charted started last night.  The man I was writing about was 59 years old.  How sad is that.  A little over a week ago he went in for routine surgery and then had a small stroke (of the blood clot variety).  He came to my hospital's rehab unit post-stroke and was there for a few hours before suffering a massive bleeding episode in his brain from the blood thinners they had put him on after his last stroke in hopes of preventing another one.  This all happened just as his family was coming in to visit him.  Needless to say unexpected and quite shocking for them.

We immediately called the organ donation center in hopes that the family would be willing to go that route due to the futility of his condition.  Unfortunately they were not willing.  In fact, they were so in shock they didn't speak more than a word or two to us for about the first 24 hours that he was with us.  Finally today they are beginning to open up and see the reality and gravity of the situation.  Code status has finally been addressed and he will not be tortured thru unnecessary attempts at bringing him back to life since he is practically brain dead already.

Such a shame at 59.  :(

Now, to end on a happy note.........my other patient was such a nice guy.  55 and in a rapid heart rhythm called atrial flutter.  His heart rate was 140-150's all weekend despite numerous attempts to control it.  Everytime we tried we ended up with either long pauses in his heart rate or dropping blood pressure.  Neither one a good thing!!

Today I was supposed to go home at my usual time of 7:15 am and after having him for 3 nights in a row wouldn't have known how he made out unless I called for an update (which I rarely do).  But thanks to 2 call outs I stayed until 11:15 (whoo hooo to 4 hours of time and a half!!!!) so I got to be there for half his day.

Today his day included a TEE (an internal heart ultrasound) and then a DC cardioversion (heart shock back into the right rhythm and rate).  His dayshift nurse (who also had had him all weekend) and I were nervously excited when he was wheeled back onto the floor to see what his rate & rhythm were...................YES NSR in the 80's.  I think we both jumped for joy!!!  What a nice outcome for this man.   Hopefully he'll stay NSR now and this will be it for awhile for him.  Home on a new med or two and that will be that.  With A flutter though I doubt it will be the last time we'll see him unfortunately.  Here's hoping though!!!!

  Atrial flutter rhythm picture

The one who "got" to me

They say that in your career you'll have at least one patient who "gets" to you. One who you become quite close to and that you never forget. That happened to me early in my career. He was this young Chinese man in his early 30's. He had chronic lymphacytic leukemia (CLL).

In the beginning looking at him you'd never even know he was sick. He came into the hospital almost monthly back when I worked on the med/surg/oncology floor. Somehow I seemed to always be assigned to him so we built quite the rapport. His wife worked an odd shift and got off around 1am and would come to see him each night after she got off so I got to know her pretty well too. What a sweet story they had....

He came to the US from China in his 20's. She was still in China when they "met" and they courted over the phone and were soon engaged. The plan was for her to move to the US and for them to be married. The day he found out about his CLL he called her and tried to break things off. She outright refused even when he told her he would probably die from this.

The doctors here told him that he had a good chance of going into remission if he would undergo a bone marrow transplant. None of the few family members he had in the US matched and the ones in China couldn't be tested. He was unwilling to take an unrelated donor specimen. The chemo unfortunately wasn't enough.

Over the months as I took care of him multiple times I watched him slowly decline. He always asked if I was working and wanted to sit and chat if I had time. I remember one night he told me that he was going to have an ultrasound in the morning as his abdomen had gotten quite hard and swollen. Trying to still have a sense of humor despite his pain and suffering he told me that "they are going to take a look at the baby in there!" As usual he had me in stitches.

One night as his disease process progressed and I didn't have him another nurse called me to his room to help her and it sounded serious. There he was in the bed having a grand mal seizure. I had such a hard time helping as it was almost like I was seeing a family member at that point. For a minute I didn't know what to do. Then the nurse in me kicked in and I was able to help my colleague with stabilizing him. Unfortunately his wife was there to witness the whole thing.

I dreaded going into work as his death became more imminent. I wasn't sure I could handle being there when he died. They talked and talked about not becoming too close to patients in nursing school for just this reason and here I was in my first year as a nurse and it was already happening. I wasn't sure I was cut out for this. I had a long talk with some of my coworkers about it all and they reassured me that you will always have at least one patient in your career that this happens with. As long as it isn't all of them then it's OK. I guess I just got mine out of the way early. This man died on the day shift and as selfish as it is I was happy that it happened then. I was completely devastated and I really don't think I could have handled being there for it. Since then I have become close with other patients but never like this.

"This is what you are meant to be doing and we will never forget you"

One night I picked up a patient from a fellow nurse and figured it would be a typical shift. We'll call this patient JJ. She was in her mid 40's and otherwise fairly healthy other than being a smoker. She came in after vomiting at home and having some respiratory distress. My coworker had gotten her all settled in and told me that she was doing fairly well and that she had pneumonia. We figured she would probably end up on a ventilator at some point in the next few days due to the way she was looking (she had a pretty bad pneumonia) but not imminentely. Ok, I say, no big deal right.........we see patients with pneumonia all the time. That's where I was wrong!!!!

I go in and say hello to JJ, do my assessment and she seems fairly stable. Out of breath with minimal exertion but I expect this really. I check her oxygen, iv fluids, etc. All looks well. Go out to the nurses station to check my labs and see what time she needs meds. I'm in the middle of this when I look over and she's attempting to get out of her bed!!! Ahhhh!! I run to her room to ask her what is the matter?? She states that she needs to get up. She is now clearly in severe respiratory distress and quite confused. This is NOT GOOD!!

I stat page the resp therapist (RT) and pulmonologist. RT comes right away but it takes 3 more calls to get the doc on the phone...Grrrr! He wants to try bipap (a tight mask that goes on the face that is sometimes successfully tried before the ventilator). He also tells me that he does not want to intubate this lady as he feels she won't have a good outcome but doesn't explain why. As she's not doing well I don't take the time to try and get him to explain I just take the orders and get back into the room.

At this point 3 people are holding her down to keep her in the bed. This is sometimes typical as people in this severe of respiratory distress for some reason want to get up and walk around!! We try the bipap which she promptly rips off so we have no choice but to intubate her and put her on the ventilator. Anesthesia is called and she is heavily sedated and intubated. Finally calm.........whew!!! Able to breathe with a secure airway. Crisis averted.........or so I thought as now she is coding and has no pulse...........OMG. This is NOT what I had expected. We start CPR and someone goes to call the doc again. Everyone shows up and we work on her for about 30 mins and get her heart going again.

I call the pulmonologist to tell him what happened and he says "well I'm not too surprised and next time when I tell you I don't want to intubate someone maybe you'll listen" WTF I think? What am I supposed to do? The woman cannot breathe. Just as I'm getting over that one though he tells me that he'll call me back in 30 min and not to call him as he's going out to dinner with his wife and another couple.......ummmm ok then. Jerk. As if I don't have enough going on I have to put up with his nonsense too!!! I hang up the phone, walk back into the room and she codes again. Luckily we get her back once again.

By then we have contacted her husband to let him know what is going on and he has come in. We get her all cleaned up and have him come in. The doctor and I update him and he visits with her. How sad to see his sadness. But luckily at this point she is still alive. He then tells me they have 2 teenage sons and I am even gladder that we saved her. Now, I'm just hoping that we did a good enough job and that she will pull through it. Only time will tell as I'm off for a few nights.

I come back a few nights later and there are her husband and sons at her side. He comes and says hi to me and tells me that he needs to thank me. I ask what for and he tells me that the day shift nurse from that day told him what actually happened that night and that if I wasn't there she wouldn't have made it. You are welcome I say but that it wasn't so much "me" and that any nurse that night would have saved her and he replies with "that's not what I was told". We leave it at that and he gives me a smile and goes back to her side. I have other patients that night.

She remains on the ventilator for almost 2 weeks to get over her pneumonia and sometimes I have her and sometimes I don't. I get to know her husband off and on. He always says hello though if I'm on. She finally is extubated successfully and remembers nothing. My heart sinks and I wonder what I did wrong that night several weeks ago. Did she go without oxygen too long and does she have brain damage now? Or is this just the lingering effects of the medications we use for sedation and amnesia when patients are on vents? Of course, I'm desperately hoping for the latter.

Fast forward another week and guess what...............JJ is back to her normal self!!!! She has no memory from the weeks that she was intubated but that's just dandy as that's what we want but she remembers everything else from her life. I'm so happy to hear this when I come in. I happened to be working the night she gets transferred out of CCU to the respiratory floor. As they are wheeling her out she says to me "my husband says I'm supposed to thank you......so thank you so much for all you did for me." Your welcome I say!! Then her sons take their turns and thank me for all I did for their mom.......again I tell them it was my pleasure. Then over comes her husband who envelopes me in this huge hug. And then comes a moment I will never forget as long as I live....these were his words: "thank you so much for saving my wife. If you have ever wondered if you should have become a nurse then look over there at my sons. If it weren't for you they would be without their mother right now. This is what you are meant to be doing and we will never forget you."

Oh my gosh did it take everything I had not to cry at that point. Not that I haven't cried on the job before...I have. But that was just such a powerful moment for me. And, again, one I will never forget.