Sunday, July 22, 2007

Only One more Day....

I should have known that last night was gonna suck big, cause Friday night went too well. I had time to go to the bathroom twice, actually sit down and eat my dinner without having to rush, and go and see some people from my old unit to talk for awhile. We had time to sit at the nurses desk and shoot the breeze. I opened the night with my favorite doc and closed it with an ok one. Even had time to try out Nurse K's fake poo recipe....Then last night.....ugh. 4 GSW, 1 DOA and unable to return the rhythm. The DOA made me even more mad when I found out that the paient had been laying in the street for over two hours according to bystanders, and no one thought to call for help! And they admitted this when someone finally decided to call 911. Two of the GSWs were together in the same bed and got shot up, none above the waist, and 2 in a very unfortunate place, between the two there were over 10 wounds, they pissed someone off... the last GSW and I quote" found a rifle in the woods behind my grandfather's house, accidentally shot myself, and threw it back into the woods, I have no idea where it is now." Likely story esp since this was a drop and run in the ambulance ramp. 2 stabbings, one which was a steak knife, 1 inch cut in the neck, which pierced the aorta, talk about an unlucky hit, didn't make it through surgery. A heart alert, a full code and an intubation, and these were just mine and my bed partners'. Didn't have time to find out about the rest of the ER. Foolishly ordered out, and brought the food home for breakfast, and still have one more night, oh well, time to hit the sack and hope for a better night.

Friday, July 20, 2007

What sense does this make?

Ok, I wanted to keep this blog out of politics and strictly on what I see in work, but had a converstaion that really got my ilk up. It was about raising the minimum wage. Now I don't know what kind of logic these people are raised on, but it is not sound. What part of the word minimum do these people not understand? Let's say that you have worked at a place for 3 years and when you started, you made minimum wage. After being a faithful and good employee, you have worked your way up to 6.75 an hour. Now all of a sudden, the feds have decided that minimum wage needs to be increased to 6.50 an hour. You have essentially just lost 1.35 of your hourly income, because do you think that corporations are going to raise anyone's income besides those at the bottom? NO!!!! So those making minimum wage are now, *gasp* still making less than anyone else in the country currently legally working, and those who have clawed their way slightly above minimum wage are knocked back down to the bottom. Now also keep in mind that the money to pay these people more has to come from somewhere, so prices will be going up to make up for the diference, this is called inflation. So what we have are people, still making minimum wage, although it is a higher amount, prices going up, and the only ones making out are the government(increased tax revenue) and politicians (it actuallysounds good on paper to propose this).

Thursday, July 19, 2007


I love almost all the docs I work with, some more than others, but for the most part they are a great group and listen to us and we work as a team to get patients out of our er as quickly as possible whether it is up to the floor or out the door. But there is this one doctor, that I just feel really has it in for me. I don't know if I have pissed this doc off or what, but there have been a coupla incidences that have made me go, huh? First one was an honest mistake on my part. I was a new nurse to the er, from an ICU that was pretty much run by the nurses, we made ALOT of patient care decisions. We also responded to codes on the floor which were run by residents, who did not have alot of experience, ergo the nurses ran the codes. I had a patient that came off of the ambulance into a bed (in a tootie room no doubt), and started "acting funny". She couldn't sit still, she was all over the bed and was complaining of lower back pain, that spread after sublingual nitro given en route, and leg numbness. Well I placed her on the monitor and was getting her history. In the middle of the history fhe gave me the Q sign. I yell out for the crash cart and help, position her in bed, and sure enough, no pulse even though there is a juctional rhythm in the 30's on the monitor. I have one of the other nurses bvm her, a tech do compressions and I put her on the defibrillator. I bust open the cart and give an amp of epi and an amp of atropine (both 1 mg), the doc has not made it into the room yet. I send another nurse for the doctor, we resume CPR, and in 3 minutes, I give one more amp of epi, monitor is showing and accelerated Juntctional rhythm at 80, still no pulse. It is then the doc shows up, and is mad because I have already given 2 mg of epi and 1 mg of atropine and the doc was not aware of the code. Well, I informed the doc I was a little busy and figured when I called for the crash cart, it might get someone's attention(which it apparently did since everyone in the er who did not have an md liscense had made their way into the room), as I have said, bad foot in mouth disease. Patient ended up not making it, and I apologised to the doc for my words and explained that I was new and we did things a little differently where I was from, but I was covered under ACLS protocols. I thought we had made up and all was good until....

We had a patient come in whose ICD was firing like every 10 minutes. The monitor showed a paced rhythm with varying runs of Vtach, though it was a perfusion vtach. When the runs were long enough, the ICD fired, just doing its job. Sats were 94%, but this was on a NRB. I ask respiratory to get me an ABG, she does and the PO2 is like 52. I show this to the doc (who is on the phone to cardiology about the patient). When the call is over, I am asked, who ordered this? I said that I asked for it to be drawn, that I thought it would be a good value to know since hypoxia could be causing Vtach, which is causing the ICD to fire, hearts act really irritable when there is not enough o2. And I get told that the order will not be signed off since this doc did not order it. I am standing there slackjawed and flabbergasted, this patient's pO2 is only 52 on 100% O2! It is not like I stuckthe patient and the gases ended up being ok. Luckily I knew the cardiologist on call very well and he wrote the order to cover my butt, but I was so madI could spit! Can anyone tell me why this doc might not have wanted ABG's?

Now that I have been there a little while and gotten to know this doc a little better we are feeling each other out little by little and getting along a little better, in fact I like this doc as a person, just not my favorite one to work with.

wrong time

Apparently I was born in the wrong era of nursing. Don't get me wrong, I love the great strides we have made as a profession and how doctors respect us more now than before (still have some ways to go there though) or how we now make a little more than minimum wage. I also don't think I could have survived in the little white uniforms (wearing essentially pjs to work every day pretty much sealed the deal on the decicion to become a nurse) seeing that 1. I hate dresses 2. I hate white 3. I am the world's messiest person, hands down. However, for all of the forward strides we have made, we now have two huge brass balls (and not the good kind like nurse k's), one chained to each leg that are slowing our strides and pulling us back, named HIPAA and one named JCAHO.

I understand that they are supposed to make things safer and more private for my patient, but, like all things beaurocratic, they have made what should be simple and easy, common sense if you will, into red tape and hoops. Let's look at what JCAHO has done to me at my job first:

1. I am no longer allowed to carry any supplies or drugs in my pocket. Nor in my ER are we allowed to keep supplies in our rooms. So let's say you are having abdominal pain, and you need pain medicine, but first an IV. I have to gather all of my equipment in the supply room (and pray to God I don't forget anything), start your IV, and flush it (if I remembered to grab one, since I used to be able to have that on my body and I am not used to having to grab one). I must then go all the way to the med room and get your meds, draw it up and label it. Then head back to your room, verify your name by your armband, you saying it, have you state your allergies, verify my med, dose and order and then give it to you. (Now I am all for the double and triple checking identity, I do believe in that part of JCAHO's fiendish plot). Let's hope you are not having a real emergency when I get in there and we need an IV started immediately, cause I have none in my pocket and there are none at the bedside.

2. If your IV pump starts beeping, I can no longer just go in the room and stop it and flush your IV. Nope, I have to stop the pump, go to the med room, get a flush and then go back and flush your IV.

3. This is the one I really do not comprehend. In our ER we have 4 sections. We have a trauma end where the really sick patients go, a middle area that stays open all night for less acute patients, and end that stops accepting patients at 2300 that is also less acute, but somtimes stays open "boarding" patients, and a fast track "urgent care" which closes at midnight. In the two less acute areas, if you happen to get a patient that needs to be intubated (which happens more often than you would believe) I have to pray I key in the right code to get into the medicine room, remember my code to get in the medicine pyxis machine, to get a key and run about 100 feet to another coded locked door, go in and unlock 2 old narc cabinets to get a locked tackle box which contains the "rsi" drugs. Then go to the patient's room. Now keep in mind that this patient is in ACUTE DISTRESS needing to be RAPIDLY intubated. Also remember that our doors keep you locked out after 3 missed tries on the coded lock, have you ever tried to type in 4 numbers on an itty bitty pad while your adrenaline is pumping through you? It can be hard. How is this making patient care better?

4. I used to be able to make it through the shift ok just kinda "grazing" at the nurses desk. Have acoupla of light weight snacks sitting below the counter and you really don't realize you haven't had a chance to eat, because you are grabbing handfuls as you chart or call docs or gather equipment and your stomach is not completely empty. In steps JCAHO, I am no longer allowed to have anything but a drink with a top on it. Now my tummy is constantly reminding me it has been 23 hours since anything has been put in it. Now I dont know about other er's but there are nights that I cant make it to the bathroom down the hall, much less to the breakroom to eat, so having a snack at the nurses desk at least kept my stomach growlings to a low roar. Now even that is gone. And I spend all night grouchy.

5. Apparently you cannot have mesh shoes or shoes with holes in them for fear of being exposed to body fluids. Now inal traumas we wear gowns and shoe covers that protect us, but in other areas, we don't. So just how is the mesh on my shoes any worse than the clothing I am wearing. If I have a spurter, and it hits my clothes, it will seep through just like if it drips on my shoes, I am exposed! So unless you are going to make me wear leather or polyesther scrubs,your reasoning makes no sense. (I have probably opened a can of worms and now they will require us to wear leather scrubs, I apologize to nurses everywhere).

6. We now have to write up "discharge" meds for our patients on their home meds sheet and fax them to thier primary doctor so their is a "continuance of care". #1. Probably 90% of our patients consider our ER docs their primary care doctors and we have their records already, why do we need to write it again? 2. The ones who have primary docs, I work nights, not just nights, weekend nights, what if I fax it to the wrong number? I have no way of knowing and we are talking MAJOR hipaa violations. 3. We don't require their primary care docs to fax us their meds prior to coming, what about our continuity of care? 4. We have ALOT with their primary docs OOT (out of town), how do we get their fax numbers (some of these docs I would really like to get a hold of, to become my primary, putting someone on 12 mg dilaudid every 2 hours, that's my kinda doc). ISSUES.

I don't have as much problem with HIPAA, just the fact that it can put you in awkward positions and it can come back and bite you when you least expect it.

My First day.....

My first post, kinda scary, I have been trying to decide what to go with, I think I will talk about my very first day as a nurse. I was a new grad who had precepted in the unit I get hired into. The unit was one that was high stress and had an extremely high turnover rate. My very first day as a nurse, my new nurse manager asked if I would not mind taking just one patient. This patient was post op day 3 from a VSD and would have been moving to the floor except all of the beds were full out there. So my enthusiasm for nursing overtook my common sense (this would set the precedent for my entire nursing career), and I said yes. She assured me that my preceptor would be able to help me with any questions or concerns.

All was going well until 915, when the patient started acting confused and talking out of her head. My preceptor was busy admitting 2 patients who had returned from surgery within 30 minutes of each other, so I called the nurse practitioner and told her that I think something was wrong with my patient, not sure what, but the patient just didnt look right. The NP said she would be back there in a minute. Upon arriving, my patient is now breathing like a guppy and I am feeling a bit guppy-ish too, I put her on a Non Rebreather mask and turned the O2 up to 15 liters.

"Have you drawn an ABG yet?" she asks.
Me standing there, looking slightly perplexed, "umm no".
"Well dont you think you should get one, you obviously think this patient is hypoxic since you went from no O2 to 15 liters" she said.
"Umm doesn't respiratory therapy have to get those?"
"The patient has an art line, don't they?"
"No it was taken out on anticipation of transferring out."
"Well page respiratory, now and get a portable chest"

So I page respiratory and x ray, and they come and get a gas and a film. The PO2 is 41 and this is after the patient has been on 100% O2 for a good 10 minutes. We page or anesthesist to intubate and notify the surgeon, who is in another case right now. The xray (according to the NP) shows an enlarged mediastinum and Pneumothorax, now I have no idea what she just said, but I do recognize the next words out of her mouth, "we are going to need a intubation roll, the crash cart at the bedside and you need to set up for a chest tube." Even though I recognize them, I had no idea what I needed to setup for a chest tube, I ask her to help me and we get it set up before the anethesist arrives. We also hung some dopamine because her blood pressure was soft and we apaced her using her epicardial pacing wires at 80.

The anethesist asks me to push 120 of succs and 20 of etomidate, I just look at him, I did not realize that I should already have the drugs. So I run and try to get them out of our pyxis, and my number does not work yet. I hunt down someone else to get the drugs. I come back apologizing while trying to pull up the meds, he is BVMing the patient, who at this point doesn't really look like she actually needs the drugs, but I push them in anyway. After successfully intubating the patient, looking at the post films, and talking to the surgeon, he decides that this patient is going to need a triple lumen and a swan. I explain to this dr (thank goodness it was one of the nicest drs I have ever met), that I had been a nurse exactly 3 and a half hours, period, and while I did not mind helping with this stuff, could he keep that in mind, and humor me if I was a little slow. Setting up a "4 way" (the device used to monitor arterial pressure, CVP and PA pressures) was something I could do in my sleep considering I had precepted as a nursing student here and this was a task that got delegated to me ALOT.

First day precepting 0700:
"Hey have you ever set up a 4 way" says Old nurse #1.
"No" I say.
"Here let me show you how it is done" she syas.

First day precepting 0800:
"Hey have you ever set up a 4 way" says Old nurse #2.
"Not by myself" I say.
"Here, I will watch you and help you out if you need it," she says.

First day precepting 0830:
"Hey have you ever set up a 4 way" says Old nurse #3.
"yes" I proudly say.
"Can you do it for me, I kinda got my hands tied" she syas.
From then on out, that became my specialty once word got around that i could do it, but i digress, back to the story.

So the patient is now intubated and I have the 4 way set up, but no clue what I need to get for the art line, central line or swan. My preceptor is to the point where she can help out and shows me what I will be needing before having to get back to her patient who just dumped 500 ccs blood in the chest tubes. I help the doc and everything goes with out a hitch, except I hook up the PA ports to the CVP port, but that was easilt remedied. The practitioner put in the art line without a problem. At that point the Surgeon has just made it to the floor, he also is one of the nice ones. He starts asking questions and I tell him what I know to the best of my abilities, he looks at the xray, and says that the patient needs a chest tube and also needs to go back to the OR. I also tell him that "I have been a nurse for only 4 hours now, and while I am not scared to help you, I want you to be aware. (while nice, he is also known for his temper tantrums if provoked)." He says ok and walked me through exactly what I needed to do. The chest tube got put in, the swan, art line and central line got placed, and the patient was intubated and heading back to the OR, and I had done it with minimum help (not because they were not willing, there were just alot of sick patients that day and they were short) and all within the first 1/3 of my shift!

After I broke down and cried because the NP came by and said "You did a really great job for a new nurse, but the fact of the matter is that the patient does not care if you have been a nurse for 2 minutes or 30 years, if they are dying, certain interventions need to be made. You chose to work in this unit, and you are expected to be able to anticipate what interventions need to be made when certain symptoms are present, this is LIFE or DEATH we are talking about. Just remember that", I took a deep breath, got some of the nurses to help me with my charting and waited for my patient to return. The rest of the shift went without a hitch, the patient came back from surgery (a pericardial window after the vsd patch leaked and caused a tamponade), and did well, went home after 6 weeks in the hospital. The practitioner told me months later, I never should have had that patient, VSDs have an enormously high complication rate, and I survived with more confidence in myself than Most after their first days. Talk about orientation by fire. Imagine my surprise when I returned to work the next day with a preceptor........