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Dec. 19th, 2008 @ 05:02 pm We're drowning here........
Current Mood: stressedstressed
Current Music: assorted Christmas music on XM Radio
The unit has moved back downstairs to our regular haunts, now that the money-making Interventional Cardiac Unit is in its spiffy new digs, the remodeling of which we had to suffer through. My first night back after that occurrence, I was disheartened but not surprised to find that our patient:nurse ratio has been upped to 4:1. While we were upstairs our census had been increased to 7 patients, with one nurse having 3 and the other 4, and everyone predicted this was coming. Still, it was a nasty shock, even if expected. Adding insult to injury, we rarely have a tech any more; there's one who works days, but only 4 a week, and one who works 2 nights a week, but rarely when I'm on, for some reason. Depending on who the supervisor is, we *might* get one for part of a shift, though there's one who will almost always give us one if she has one to spare.

Oh, and the patients? Well, surprise, there's no decrease in acuity. We still have all the cardiac and vasoactive drips, our chronic vent, the recently extubated, complicated wound care, blood to give, and those who aren't too terribly tightly tied and like to climb out of bed and do "face plants" on the floor, not to mention a few who think they have a private duty nurse who will cater to their every whim. This morning we got a call "Can you take a labetolol drip?" (this is a continuous infusion of a heavy-duty blood pressure drug which can take a nasty turn if you're not careful) and the oncoming charge nurse said "No, not even if we had a bed, which we don't." Technically we *might* take such a thing, but it would be dangerous with the number and acuity of our current patient load. Oh, and the category I forgot......the gynormous, those weighing over 300 lbs., who are killing our backs and shoulders.

And how do they justify all this? It's being done in the name of "productivity," a model designed by the bean counters who have no clue about what really goes on out here in the world. Everything is measured by some formula which appears to be completely divorced from the reality of caring for the sick. "But we have to make money to keep going!" they wail. Right, and how many of YOU do we need? How much middle management is required to keep an outfit going, and why does the CEO need to make that much money? My dearest dream is that part of the curriculum for all programs in health care administration will include a year actually working as a tech, and at least 6 months closely shadowing nurses in a variety of units. In the best of all possible worlds......but it will never happen.

The result is burnout, despair, and a lot of bodies heading for the door. Our assistant manager left for one of the critical care units; one of our best day nurses took an assistant manager position at a smaller inner-city hospital; another went back to New Jersey; and almost everyone else has applications out or is looking either in the system or out. Of course there's a hiring freeze on in the system, it being the end of the year and all.

I thought about posting an account of what happened last night, but just thinking about it makes me exhausted all over again, and considering what we might have overlooked is painful. Meanwhile our other 7 patients went unattended, and one nurse was there for nearly 20 hours... ame in for day shift, stayed over for 4, and it was her patient that tanked, so she was there past 1:30 charting. Please tell me how this can be safe?
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Nov. 9th, 2008 @ 03:47 pm Fatigue
Current Mood: exhaustedexhausted
The other night while I was wandering about on Wikipedia (a favorite pastime of mine in slow times at work because I can leave it and come back to where I was) I came across a term I hadn't heard before but which made sense to me..."compassion fatigue." It's defined thus (with a nod to the wiki folks):

"Compassion fatigue, also known as a Secondary Traumatic Stress Disorder, is a term that refers to a gradual lessening of compassion over time. It is common among victims of trauma and individuals that work directly with victims of trauma. It was first diagnosed in nurses in the 1950's."

There's a lot more in the article, some of which I have quarrels with, but it does explain quite a lot that may allow people on the other side to understand those of us in the helping professions. (I think it also explains a lot of the very dark humor common to doctors and nurses...it's our attempt to cope with the overload)

I can see how it might well affect the way we look at our patients sometimes, particularly long-termers or "frequent flyers" (a.k.a. "repeat offenders") whose problems are often of their own making. Case in point: we have a female patient who is about 5 ft. tall and weighs close to 400 lbs. She's had problems directly relating to her weight for a long time, and sometime within the last couple of years one of the additions to her being has been a permanent tracheostomy. She has respiratory problems, of course; she's a little person, probably with rather small lungs, inside a positive MOUNTAIN of flesh. I think her current admission has lasted a couple of months, and she's bounced in and out of CCU several times. The last time she came out of CCU she ended up with us. She'd been in CCU that time because during a transport downstairs to CT or someplace either the oxygen was not turned on or the tank was empty, and by the time she got where she was going, she was unresponsive. Big OOPS. Anyhow, we've had her since sometime last week, and over the last few days she seemed to us to be really going downhill. Her O2 sats (a way of measuring oxygen levels) would go into the 80s at night, yet the docs didn't seem concerned. Since this past Monday or Tuesday night, the nurses have been eyeing her anxiously, watching her levels drop, running in to wake her up and remind her to take deep breaths...but the docs didn't seem all that concerned. One of them actually said that if they were "88 or so" he wasn't going to worry. It was like they'd got so used to her looking like crap that they didn't even see her any more. Thursday night I had her and a couple of other patients...one a gentleman who was going for open heart, the other our lady who'd finally come out of her DTs and was getting blood. Starting about 4:30 I was busier than the proverbial one-armed paperhanger, trying to get my gentleman prepped (we had no tech, of course, which is the norm any more), worrying about my other lady who was having increasing shortness of breath, running in to remind Ms. Big Girl to "breathe deep, get your chin off your trach!". She was already on 100% oxygen by trach collar, noplace else to go with that. By the end of my shift, I'd had to take my guy downstairs to surgery, and the lady with breathing difficulty was in full-blown pulmonary edema. Did I have time to worry about Ms. Big Girl? Hell no! That night I came in to find the patient who had tanked was all better (amazing how fast you can fix pulmonary edema!), I had a new patient, and.......wait a minute, where is she? There's nobody in that room! Furthermore, the guy I was to get report from looked tired but was grinning like an idiot. Seems he got a bit aggressive with the docs and finally got one to order blood gases.....which were so horrible that they had no choice but to ship her back to CCU. (I'm sure they were no more pleased to see her than we had been!) There she lingered, not on the vent yet but continuing to do what she'd done for us.....until this morning, when one of my favorite respiratory therapists came by during report, waving some tubing, and said "Guess what? Pressure support to the trach collar, ever heard of such a thing?" That was exciting to us, because it means that she's essentially on the vent, and *that* means she can't ricochet back to us, at least for awhile.

A different kind of fatigue is infecting my sisters (I say that because there are very few guys working in any of the critical care units) in CCU and CVICU. I know there have been some horrible things happening there...a 37-year old who came in with what seemed like a fairly simple, though bad, urinary tract infection, who crashed and burned and died of overwhelming sepsis; an 18 year old girl with pneumonia who just isn't coming off the vent; some guy down in CVICU who doesn't look all that old but is connected to just about every machine they own; and yesterday a 27 year old kid in CCU who essentially has no heart left, who coded 3 times before they shipped him down to CVICU to work him up for transplant and do whatever it is they do down there that CCU can't do. When CVICU had a code we all thought it was him, but apparently it was the dude on all the machinery, as they were just cleaning up when I went down to the chute (it's located in CVICU) to drop off lab work. This morning on the elevator I bumped into Claudia, who works down there. She looked exhausted and just about to cry, and I said to her "You guys had a rough night of it." She said, "It's been a rough week! This was my fifth night this week and I can't come back any more, there are just too many sick, sick people!" I know exactly how she felt. I submit that we all know that at some point.
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Oct. 25th, 2008 @ 03:09 pm I score a coup
Current Mood: satisfiedsatisfied
I have been a major bad blogger recently, no excuse except I just haven't got around to putting things down. I've slowly been getting involved in things here...a jewelry class, for one, which I absolutely LOVE, and exploring some of the cultural and other opportunities. I was going to go to the local Highland Games today, but it's cold and rainy, weather so awful that I suspect even the native Scots would complain, so I'll wait and see what it's like tomorrow.

Some other things have happened to make me think. A good friend's brother died in a freak accident, suffering a traumatic brain injury; he was an organ donor and was in good health, and I am told that as a last act, even though it was not a conscious one, he gave "right down to the marrow of his bones." At almost exactly the same time, I heard from one of my dearest friends in the entire world (literally--he lives in Israel!) that he had been placed on the list for lung transplant and was told that the average waiting time there was 4-6 months. Not that one affected the other, but it seemed an odd coincidence that they happened so close together. Less than two weeks later he was called to the hospital and was actually prepped and waiting for surgery, lying on a gurney with arms outstretched...and when they opened up the putative donor, the lungs were in too bad a condition to use! I got a very funny e-mail from him after that, entitled "Dress Rehearsal Rag," detailing what went on and what he thought. (With his trademark off-center humor, he described his position on the gurney thus: "They spread my arms out from my body, supported by the arm rests, and attached the IVs etc. to them... And i glanced at myself and thought: Hey fellas, just remember what happened the LAST time they stuck a Jew on a cross...") Anyway, about 10 days ago he was called to the hospital again, and this time he actually HAD his transplant. He was supposed to be discharged on Thursday, but I have not heard yet from either him, his son (the designated communicator, who gives "taciturn" a whole new meaning) or his erstwhile girlfriend that he is indeed home.

So on to last night, which was busy but not horrendous for me...and was hideously so for my partner, who inherited not one but two from CCU, plus one that I'd had the night before...which was the one giving her fits. When I'd had her she was pretty confused at night and had some issues with her blood pressure, but not totally out of character for a 70-something with a sacral fracture and on some pretty heavy-duty pain meds. Last night, however, was an entirely different story. Apparently through the day she'd had increasing problems with her blood pressure, or as the day crew said "We kept thinking her head would blow off!" and they'd finally decided that since she was also trying to climb out of the bed, the problem was anxiety, and they'd gotten an order for Ativan which chilled her pretty much...until about 8:30, when she woke up and was utterly, totally, and completely bonkers. And then her blood pressure started to climb to unreal levels. At that point something started niggling at the b back of my mind. I'd seen this before...and history of multiple falls recently...do you suppose? So I wondered aloud if she'd been taking something before she came in that had somehow escaped her med list, something like Xanax, maybe...a favorite drug of little old ladies and one that has notoriously nasty withdrawal. Still, the more I looked at her, the more I thought of something else, and I said to my partner, "You know, she looks like the DTs." My partner didn't think so at all, and between dealing with that patient's blood pressure and the correspondingly low pressures of the one in the next room, and the trauma survivor besides, she didn't really have time to think about it. I didn't say anything more, but the thought didn't leave my mind. Meanwhile, the patient's blood pressure kept climbing, her anxiety level kept rising, she had tremors, and her behavior became more and more bizarre. All meds to control the blood pressure were proving useless, and when the patient became sweaty and wheezy, she called the doctor. Of course it was the on-call, and she had to go into the history, but he asked one very pertinent question: could she be in withdrawal? While we waited for him to come up, we went into her room and she asked her a few pointed questions, like did she drink and how much and what. We got some confused answers, but enough to make us conclude that this might just be the problem. And when the doc came up, he took one look at her and said in his Chinese-accented English, "Yep, she is in DTs." From then on it was pretty straightforward detox orders...ativan, banana bag (IV with multi-vitamins, so called because of the yellow color of the fluid), B vitamins, etc. She chilled out...and didn't her blood pressure come down?

I guess people don't think of little old ladies having drinking problems. Nobody probably thinks anything of granny's nighttime glass of wine; hell, my own grandma had her *one* glass of Mogen David before bed every night of her life, though she would have been quite offended if anyone had offered her a second. But alcohol can be anyone's problem. I lived with it for a long time, and worked at one time in a unit where, if we didn't have two or three drunks or druggies detoxing, we just weren't living right, so maybe I just picked up on it. Did I feel vindicated? Yes. Did I gloat? No, because I have missed things that should have been obvious, and I will again. Still, it feels good to know you're right now and then.
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Sep. 7th, 2008 @ 05:54 pm (no subject)
Current Mood: sympatheticsympathetic
I think this post might be a mixed bag..part rant, part reflection, part I-don't-know-what. I'd meant to post something a week or two ago about how you get to know people in the wee hours of the morning and somehow it never got written.

As most critical care folks know, baths are primarily a night shift thing. I don't necessarily agree with that, at least not in the case of folks who are alert and oriented and can do at least some things for themselves, and especially not if they want to SLEEP! But if they are wakeful, as many older folks are along about 4 or 5 in the morning, sometimes it's a good time for a wash-up and a bed change. There's something about the process of doing all this that invites conversation and recollection. I've always been one who likes to listen to stories, so maybe I'll ask the patient a few questions, and often the stories just pour out. Maybe they're tales often told but now to a new audience, or maybe the patient hasn't had anyone to listen to them in some time. In recent months I've heard stories from a World War II bomber pilot, mostly about the base in England where he was stationed rather than about his missions...most veterans don't want to talk about those in specifics...and from a man who was a medic in the Korean War. I've learned what it was like to be a very young bride just after WWII. I've delighted in the stories of a woman who was one of eight girls in a family of eleven children, and laughed with her about what it was like to line up to get your hair braided in the morning.("You'd better have the knots combed out before you got to mama, and the bigger ones combed out the little ones' hair.") Everyone has a story, and I find myself making little notes of things I might want to remember if I ever stop doing other things long enough to sit down and write seriously. But I have to admit that I don't like being *expected* to give those baths whether the patient wants it or not.

Last night my partner and I had a couple of very "busy" patients. Hers was far busier than mine and far more sad, a woman dying of ovarian cancer, a retired nurse, sister of one of our docs, scared, in pain, disoriented because of some of her medications. I think she would like to let go but thinks maybe her family isn't ready. She's DNI--do not intubate--but not yet DNR. My thinking is that she might be ready for hospice, but I am not so sure about her family. Last night I sat with her for a few minutes while her nurse went to get something for her, and we talked about grandchildren, which seemed to divert her fears at least for a little. Stories....

About my patient, I don't know whether to be sad or very, very angry. He came from a nursing home, and the story is that he was essentially "dumped" in our ER from a handicapped van, emaciated, with a leaking, corroded, non-working feeding tube. (Those don't get that way overnight, folks!) The feeding tube was replaced and the area cleaned up and he was sent up to us. Okay, so he has a history of alcoholism and smoking and respiratory failure and lung cancer (chemo and radiation), and he has a trach so he can't make himself heard.....but how did he get to his current state just since April? He told me he used to weigh 198 lbs; when he came to us he weighed 100. He looks like a damn concentration camp survivor! To me the damning evidence is the condition of the feeding tube when he was admitted. I know nursing homes are understaffed, and that so many of the workers are undertrained and overworked, and many are burned out, but surely *someone* should have noticed and referred him to the doctor. Did he just not get attention because he's quieter than some of the other patients? He's perfectly alert and oriented and can make himself understood if you just take the time to pay some attention. Did they keep pouring tube feeding formula into the tube and letting it go who knows where, or did they stop just feeding him because the tube wasn't working? Who let it get this bad? It's a pretty damning indictment of this particular nursing home, at least in my not-so-humble opinion. I don't know what family he has, a sister I think but no one immediately available, so it seems there is no one to advocate for him. For now I just have to do what I can, manage his meds and his feedings, keep him turned and dry and clean, and hope to hell someone picks up the ball that got dropped. I need to remind myself to hunt up a clipboard for him tonight so he'll have a surface he can write on when he wants to tell us something.
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Aug. 9th, 2008 @ 09:17 am ...and the circle goes around
Current Mood: pensivepensive
There is one sure thing in this life...somewhere, somehow, we are all going to die. Most people don't want to deal with that or even think about it very much. In my job it's inescapable. Death is as much a fact of life as shit. Period.

In recent weeks there's been a lot of it around. We've had an inordinate number of DNRs on the unit, a fact that displeases some who still seem to feel that Do Not Resuscitate = Do Not Treat. I feel that way about some of them, who are obviously in end stage something-or-other, but we get others who are not there quite yet and can be treated for an immediate problem that is affecting their current quality of life. Then there are the ones who *should* be DNR and aren't, usually because their families either don't understand or completely deny the reality of their situation. Those are the ones you just hope code on someone else's time or unit (is sort of joke, ok?). I just wish the docs would be more forthcoming with the families and also with the patients, and would make some kind of decisions themselves about the appropriateness of treatment. How aggressive should you really be with a 98-year-old bedridden person from a nursing home who suffers from dementia, resists everything you are trying to do for him, hits and spits and is generally combative unless asleep, can't swallow and pulls out feeding tubes, is incontinent of everything, etc.? I'm not saying play God, I'm just saying be realistic with the families!

The other night I had a patient transfer from another floor. He'd been admitted earlier in the day with probable sepsis, but his underlying diagnosis was an abdominal cancer with metastasis. When I saw him, I just got a sinking feeling. Sometimes you look at a patient and the first thing you think is "Boy, you gon' die." That was exactly what I thought. He just looked BAD. When I looked at his chart I saw that while he was not a full DNR, at least he was what we call a "Chem Code" which means you support his blood pressure if it bottoms out, but you don't do compressions or intubation or anything of that sort. He floated along doing okay for the first part of the shift, blood pressure sort of on the low side but not anything unexpected. Around midnight I had to get an H&H (hemoglobin and hematocrit, a quick study for anemia) and when I got critical results I could see he was losing blood somewhere. Okay, nurse mode on. I woke up the on-call (not his regular oncologist who'd admitted him) and had to give him a complete history because he had no clue who this patient was and knew nothing about him. I got orders to type and cross and transfuse, which was about what I expected. Type and cross and getting the blood ready takes about 3-4 hours, so it was almost 4 a.m. by the time I was ready to get it going. That was also when the fun started. The patient complained of nausea and was given a basin; by the time my co-worker got back with the blood he'd barfed about 250 cc of coffee-grounds stuff, a sure indicator of GI bleeding. His blood pressure also dropped. I got the blood going at a pretty good clip, and his blood pressure continued tanking. After about 15 minutes we all looked at him and made the decision to call the house doc to check him out, a good move as it turned out. He took a look at the patient, called the on-call again (who basically washed his hands of the whole thing) and then had an extensive phone conversation with the patient's wife. Meanwhile we were pouring fluids into him and running the blood as fast as we dared at the same time. He continued to spiral downward. I'll spare the details for those faint of heart. At 7, one of my co-workers saw that I was overwhelmed and behind with my other patients, and he took over care of that patient since he was staying until 11. The wife had come in, and the last thing I saw of them, she was holding his hand and bending over him talking quietly. She had decided to make him a complete DNR. He died a short while later, very peacefully....just slowed down and flickered out on the monitor.

The next night I had my first experience of being floated...to PCU, not a favorite place, apparently, but one we have to go to frequently from our unit. For some reason they can't keep staff. Things went along reasonably with my patients, three ladies with long drawn-out tales of home stress, and I finished my charting and was on my way to do something or other when I heard some commotion in the room directly across from where I was. "She's in some weird junctional rhythm!" "Well, get a pressure!!" The next thing was "Call Rapid Response!!!" so I picked up the phone, dialed the number and got the Rapid Response team called and the house doc paged, and before I put the phone down it had turned into a Code Blue. People converged from everywhere and I got the crash cart. I didn't really take part in the code except as a gofer and some handing of supplies, but apparently I was needed.

Twenty-five minutes later it was obvious that there was no bringing this one back, and the house doc called it. Everyone dispersed, leaving the usual hideous mess behind. About that time ER brought up a new admission and people got busy with that. The tech was getting ready to clean the code patient up so her family could see her, and I volunteered to help. That was when I realized who we'd coded. You can't see the patient when they're surrounded by nurses, RTs, and docs all working on them. But I looked at her armband in total shock. It was the woman I'd gotten to know while I was orienting to CCU...the one who had grown up in my home town, only a mile from my house, who knew where my house was as I knew where she'd lived, who'd gone to the same high school I did but years earlier, who'd married a flyboy from the local airbase and moved away. Somehow I was glad I was helping to get her ready for her final journey. I was able to tell her son, when I gave him a bag containing the few personal effects she'd brought to the hospital, that she and I had shared a connection and some memories when I took care of her, and he seemed grateful to hear about it. That circle had just come round.
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Jul. 6th, 2008 @ 03:56 pm SHIIIIIIIIIIIIT!!!!!!!!!!!!!!!
Current Mood: dirtydirty
Everybody in nursing knows that in this business, shit is a way of life. Sometimes we put it more politely, but especially for those in critical care venues where techs are sometimes few and far between, it *is* a way of life. We are intimately familiar with excrement in all its permutations and can discuss it at length if called upon to do so. It's also something we usually end up laughing inappropriately about.

In any case, last night was one of those nights. I had the same two patients as before, plus a new one who came in on day shift. All of them were total care but one of them could at least move some. It's a good thing, too, because she was the one I was changing and cleaning up........every hour on the hour, it seemed! She's maybe got a partial bowel obstruction, but there's *something* going on there in any case...abdominal pain, nausea, and anorexia that's not just from the cancer.
Then towards the end of the shift my patient who'd had the brain abscess was on the call light, and when I went into her room she said apologetically, "I think I've messed myself." Boy, had she!
From her waist all the way to the foot of the bed!!! And she does not move well, so it took both of us (of course we had no tech) to clean her up. Thing is, there's a gadget called a Flexi-seal, sort of like a Foley catheter for the other end, but it is only really effective for the liquid stuff, and people here are reluctant to use it. I'm not, but it's a hassle to get an order. So, back to the cleanup...and cleanup........and cleanup. It's a bad thing when you feel like you need a shower before your shift is half over!
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Jul. 5th, 2008 @ 05:07 pm Quality of life
Current Mood: thoughtfulthoughtful
For awhile there I thought I was going to have the kind of patients that didn't give me much to talk about...a smorgasbord of cardiac arrhythmias in patients who could pretty much do for themselves, just needed some tuning up with drugs. Then last week I got a guy who was pretty much of a train wreck, history of head, neck, and bladder cancer but with acute problems having little to do with those...septic as hell, with an apparent intra-abdominal abscess that was draining bunches of gunk, and a rapidly dropping blood count that may or may not have had anything to do with it. The night I got him I was basically stuck in the room all night, giving blood and platelets just as fast as I could decently run them, trying to hydrate him enough without filling up his lungs, and eventually attending to the (ick) drainage from where the abscess had been opened up. The next night was more of the same, without the blood transfusions, but with a couple of patients added....a new onset diabetic with some seriously weird family dynamics and a post-op laparoscopy who'd had some arrythmias the night before but was fine for me except for having to get up to pee about every hour on the hour, a process requiring something like an expeditionary force to accomplish. That was an exceptionally busy couple of nights! I was thankful for the 4 nights off I had taken for a birthday holiday.

So this week it's back to work, and my first night back I picked up a new admit. It seems that the Short Stay unit is pioneering a rapid admissions model, but I hope this patient wasn't indicative of what they're going to do, because they didn't do much of any of the admitting process. That would have been bad enough, but my unit had only 2 nurses for the patients they had, and she made #7...and there was no tech. Needless to say, nobody was very happy. The patient is a 62 year old female with cancer who's been in either the hospital or rehab since March. She looks far older than her stated age and has already made herself a DNR. At this point she was just sick, diagnosed with pneumonia and a heart rate in the 140s. She was on an amiodarone drip and it didn't seem to be working all that well. She was also on antibiotics even though her white count was only 6.6, not indicative of bacterial pneumonia (hello, antibiotic resistant bugs!) and basically felt like hell. She just wanted to be left alone.
A couple of other rather unremarkable patients kept me at least somewhat busy. Last night I came back to find she was still there and I also had another patient who was a total train wreck. This one had been in NeuroVascular ICU since January! She's an old (1999) heart transplant and dialysis patient who showed up on New Year's Day with altered mental status and seizures. Her course had been one horror after another....brain abscess, craniotomy to drain that, prolonged time on the vent with failure to wean, which led to a trach, blood clots which meant she got a filter to deal with that, PEG tube with feedings which she sometimes did not tolerate, just one thing after another. She came to us on the one day I had off before I started this weekend. And guess which one is NOT a DNR? Last night she refused her 4 am feeding, did not want a bath, and only wanted the bare minimum of care. Well, if I'd been in ICU for 7 months, I wouldn't want to be messed with either! When you're in there, someone is always doing *something* to you, there are lights on most of the time, and the noise level can be pretty hideous, if not your alarms, the ones in the next room....who wouldn't want nights of dark and quiet and minimal messing-with? I personally think baths on night shift are pretty barbaric unless the patient doesn't really know what time it, and both my ladies were alert and oriented x3 and well within their rights to refuse a 5 am bath.

All this only strengthens my resolve that I will NOT be that kind of patient. I do not want to be in the hospital having things done to me if my outlook is that bleak and I have no better quality of life than these ladies. Of course I don't want prolonged dialysis either. It's a tossup whether dialysis or a trach would be worse, but I guess it would depend on how well I could get around. In point of fact, I don't want either. Just give me my pain meds, leave me alone, and let me go wherever it is I'm going. Thank you very much.
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Jun. 7th, 2008 @ 06:31 pm What would you do to someone you love?
Current Mood: thoughtfulthoughtful
I'm just off working 6 nights out of 8 (well, yesterday, actually, but was too tired to write anything), 5 of them in CCU, and the one thing I took out of there is a question...why must people subject those they supposedly love to horrible things? I know the conventional wisdom is that it's because they are poorly educated by the medical establishment, but things I have seen over and over belie that statement.

This particular case was a man who came to the ER in respiratory failure, but with so many other problems that he was almost a one-man Merck manual. Diabetes, end-stage kidney disease, peripheral vascular disease, and chronic obstructive pulmonary disease were just the high points. He'd recently lost one leg above the knee because lack of circulation led to gangrene, and the suture line looked horrible, dead for an inch on either side. The other leg was looking pretty much the same way, necrotic just about all the way around the calf. Necrotic areas on the fingers, too. Decubitus on the sacral area darn near to the bone. He'd been getting tube feedings but hadn't been tolerating them, so they were suspended. He'd been on the vent long enough to be trached and for the trach to be nice and solid and not draining any. He was barely responsive, only withdrawing to painful stimuli, would open his eyes at random but didn't track, didn't follow commands and barely moved at all, certainly not purposefully in any way except for the withdrawal. A recent EEG wasn't flatline, but showed diffuse slowing, in other words very little brain activity. Most of us would call him "dead on the vent." His family (wife and numerous kids) has been told, in very blunt words, that there is no hope of recovery, that he's not really in there, yet they don't seem to get it. "But he opened his eyes and looked at me!" (No, he just happened to be turned that way) "But he moved his hand when I touched him!" (He withdraws from all touch) So we continue to maintain him on the vent and on dialysis three times a week, and we do all sorts of things to him, many of which are painful...and pain is the only thing that seems to reach him. Why? I think the short answer is "because we can, therefore we have to." Nobody, least of all the family, seems to be looking at his quality of life, and no one will make the decision to do the compassionate thing, to stop all the painful treatments, stop his dialysis, keep him comfortable, and let him go peacefully. After all, his heart (an electromechanical pump) is still beating, and could go on beating for a long time, even if his brain did go flatline, so he's "alive." Right. Lying there rotting while a machine breathes for him and three times a week another machine filters toxins from his blood because his kidneys don't do that any more. Where's life in that?

I have informed my children if they even consider doing such things to me when I can't protest, I will sit on the heads of their beds and haunt them for the rest of their natural lives. Think about it. How much would you torture someone you loved if you knew there was no hope of recovery? And if you haven't already done so, make your advance directives so no one will do the same to you.
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May. 18th, 2008 @ 06:32 pm settling in and other oddments
I'm now about halfway through my orientation period and feeling pretty good about it. I've been taking the patients on the team, leaving my preceptor (usually the charge nurse) free to help out wherever...the other night she was about to fall asleep so she volunteered to be our tech for the night, since our real tech had been pulled. (This is more usual than not, and I'll discuss that later, or maybe another time.) So now I take up to three patients, depending on our census, and do admissions with all the attendant paperwork, and draw labs, and enter orders, and all the usual stuff the night shift does.

Our patients are not quite as critical as advertised, for the most part, but occasionally we'll have one who's pretty sick. Actually our sickest patient is chronic, and if she could get stable enough she really belongs in skilled care or maybe even rehab. She was in a horrible MVA last year sometime and she's lucky to be alive, if you can call her current status living. She must have been in a bad T-bone crash; everything on the left side of her body was smashed. She was on the vent for an unconscionable amount of time and still has her trach. Had a PEG tube too when she arrived, but no longer does. An external fixator on her left humerus. Foley, of course. And naturally, decubiti from hell, including one I could probably lose my fist in. There's a total of six dressings, but only two of them fall to my shift, being twice a day. The first time I did them it took me an hour. I've gotten faster and learned to combine the dressing changes with her bath, which means she gets cleaned up at an unearthly hour, but I'm not real sure she knows what time it is since she's been in the hospital for so long. I suspect she also has a traumatic brain injury--how can you get that much of you smashed and not have one?--although some think she has ICU psychosis. Well, why not both? Anyway, after an initial period of circling each other cautiously, we seem to have come to a point of actually liking each other. At least she usually smiles at me when I come in, and I'm beginning to think we have similar senses of humor. One night when I had finished the worst of her dressings and rolled her back onto her back preparatory to doing the other, she looked at me and said "I need a drink!" I said "So do I!" and we both laughed fit to kill. She gave the nurses hell on Thursday, but when I came back Friday she seemed glad to see me. That does kind of make me feel good.

My apartment is sort of stuck right now until I can get some paycheck into it, so it looks like I'm still moving in. I think once I get my queen mattress in and can move into the master bedroom the puzzle will unlock. I've started on my garden, gotten it tilled at least, but lately it's rained almost every day I've had off, and I can't get the raised beds built, so all my plants are sitting in their containers on the patio. When I do manage to get it in, I'll have tomatoes and peppers, green beans, greens, radishes, beets, cucumbers, eggplant...and sunflowers!

And now for a non-nursing note...this morning I got up and as usual while having my coffee perused various news sites from places I used to call home. Imagine my surprise when I saw this picture on both the local paper of my former home town AND a tv station website! The occasion was the dedication of a new veterans' memorial for Iraq vets, of which my son is one. He's the skinny guy on the right front of the pic. His name doesn't get mentioned in the article, but I knew he was working on the project. It's just like him to do the backstage work and let someone else do the talking (the husky dude on the left front, who is his best buddy in the guards). He can't help being so photogenic! Am I proud of him? You bet....but I wish he hadn't had to go, that one of the guys he worked with hadn't encountered a roadside bomb and been permanently disabled, and that so many hadn't been killed and wounded. Now his outfit is on alert again...dammit, somebody stop this insanity!!!
Anyway, here he is, my pride and joy.
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Apr. 26th, 2008 @ 08:22 pm Jilly settles down at last
Current Mood: cheerfulcheerful
Current Music: whatever's on public radio right now
I debated whether to end this journal entirely, or just change the title. I couldn't see just leaving it here and going somewhere else, and I didn't want to start a whole new one here, so...why not just change the title?

I've been here in Capital City for two weeks, and it seems like I've been here forever. Part of it is that I was here as a traveler a couple of years back, and I'm living in the same part of town I lived in then, only south of the main drag instead of north. I know pretty much where everything is, what supermarkets are where, and (very important!) where Wal-Mart is. I wasn't as familiar with this side of the main drag, so I was delighted to find things like a neighborhood Indian restaurant and grocery store right up the street. I know where the libraries are and have decided I like the older branch better than the new one. I've found the post office. And best of all, my new apartment is just over a mile from the hospital.

My apartment is in a townhouse community and is spacious and quiet. I wanted a townhouse because I'm tired of people stomping around overhead and didn't want to live on a third floor somewhere. I'd actually been looking at another complex, but when I found this one I knew it was right. It's not a huge community, and though there are quite a few kids, it's not overrun and they seem to be well-behaved. I couldn't imagine living in an adults-only community! Downstairs I have a kitchen, dining area, and sunken living room with a *working* fireplace. Upstairs are two bedrooms and two bathrooms. I have a private patio and even a small garden plot
(and yes, I do plan a tiny kitchen garden!) as well as a small area out front where I can plant flowers.

OK, the hospital. It's HCA, which has its pluses and minuses as they all do. Decent benefits and retirement plan, pretty reasonable working conditions, and this particular one has an excellent reputation. The minuses are an antiquated computer charting system which I am already familiar with from other HCA hospitals, and maybe not the most up-to-date equipment. But everyone has been very positive and very welcoming. Probably the only place I've felt that welcomed was the one where I was last summer. I've done my mandatory week of nursing orientation and Sunday night I start actually working. Amazingly, they're not making me orient on days for a week either; I start right in on nights. I never could figure out why most places make you do day shift orientation first; it's a completely different animal from nights. One excuse sometimes given is "so you get to know the docs" but you don't see much of them during the day because you're busy running yourself to death. But then you have to learn a whole new routine when you go on nights, and that loses you another week. I'm delighted someone has actually seen the light!
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