code blog: tales of a nurse

ERNursey wants to know: What do you people do with the christmas trees off the flo-meters anyway? Why do you take them off?

Not a comprehensive list by any means:

1. Take them off the flow meter, add some beads, and you can make a kick-ass ID Badge lanyard.

2. A naughty little addition to that voodoo doll you made.

3. As, well, Christmas/fir trees for your kid's miniature doll house yard.

4. They go for about a buck apiece. They're always in demand. I think patients steal them and sell them on the black market.

5. Respiratory Therapy hoards them.

6. Add a little ball on top, some wings on the back, a little halo: instant green angel finger puppet.

Okay, so the real reason we take them off the oxygen flow meters is so that we can put them on the portable oxygen tanks when the patient goes off the unit. Why don't all the portable oxygen tanks have them? I don't know. See above.

The other reason we take them off is because when someone is on a high rate of oxygen (my own personal threshold is about 4L/min) we like to add humidity so the flow doesn't dry the patient's nose so much. Adding the humidifier requires us to take the adapter off the flow meter so that we can screw the water bottle directly on to it. The little green tree gets set down and the next RT that goes into the room scoops it up.

It's like a compulsion for them. Kind of like RN's and pens.

I hope that answered your question! Anyone else??

"milly rn" writes:

Another day, another patient - of kuwaite nationality. No surprise I work in an icu in a private hospital in london uk. kuwaite families ship their loved ones out to london when given any kind of grim diagnosis in the misguided hope that we over here will be able to fix the problems! they usually arrive half dead having been rotting in one of their own country's hospitals for weeks ( tip - dont get ill next time you visit kuwait) all paid for by the kuwaite government (nice lot arent they!)

Anyway mama m arrived, supposed to be very sick ventilated unstable blah blah blah........... in a wheelchair launched herself into her bed on arrival with no assist (we didn't have time to get near her such was the speed of her action all we saw was a blur of black cloth) and proceeded to mime the urgent need for food and beverages moi moi moi sista!!!( translation -water water water sister!!)

moi & munchies were obtained, mama was happy, family were happy. doctor not happy - mama had a K of 7 and no percievable kidney function at all. cue bit of action.....insertion of 1 vascath, trundling out of 1 Prisma CVVHD machine....priming of machine ........attachment of mama to said machine. followed by 12 hrs of machine alarming constantly..... stopping constantly... generally not doing its stuff..mainly due to the fact mama was a rolling around in the bed...as you in the know will know, not good for flow in a vascath not good for attempting cvvhd (or to the uninitiated the sort of continuous dialysis thingy we do in icus for clapped out kidneys & clapped out patients)

mama could not sleep (nurses could not read gossip magazines), due to the godamned racket the prisma machine was making & also probably if im honest due to the nurses (me & collegue) stomping up to the machine cursing & restarting it approximately 500 times every hr.......for 12 hours........

mama who supposedly spoke not one word of english apart from the term sista (nurse) announced wearily in the morning-'mama no sleep machine crap!' i was very impressed! that woman will go far in this city of ours.

I wasn't sure if I should post that submission, because it is a bit insensitive and because I don't have the patience to edit it enough to read smoothly. It's literally been in my inbox for 2 YEARS and every time I read it, the end just cracks me up. Because sometimes the CVVH machine is crap. -ed.

"Catheter Commander LVN" writes:

Having worked for 2 years in the ER, my experience became most helpful when I went into Correctional Nursing. You ask, "why do they fake a seizure?" They fake it for several reasons here: To get out of their cell when the facility has been locked down. To get the attention of staff. To get to an outside facility (hospital) where the women are much more abundant and prettier and the FOOD is sooooo much better.

We now on a case by case basis use the hand drop, pen across the nailbeds and brushing of eyelashes to determine validity of the "seizure." We're running about 95% on the FALSE side now. Before, we just tossed in an IV, threw on some O2 and out the door they went to the hospital. Since we started doing these checks, the seizure activity has slowed tremendously, go figure. Its nice to see them walk back to their cells, head hanging with a write-up for attempted staff manipulation.

And finally, "loved nursing RN" submitted this:

My mom, an active 83yo was fine till she got hit by the truck called CNS Lymphoma. Getting her admitted to , we thought she had a good chance at recovery. The last 7 months have been a nightmare with hospital acquired infections, 3 rounds of pulmomary edema, poor transfer of info at change of shift, blatant lies by staff from nurses up to and including administrators.

The infection control standards are appalling, compassion lacking in most of the doctors and NPs even knowing I am a nurse with a wide variety of technical skills did not put them on guard to do the right thing. No they would argue that keeping a used red rubber suction cath in a liter bottle of saline on the FLOOR was acceptable clean technique. Administration would never acknowledge a mistake. When I suctioned mom myself because of a 2 hour wait for the nurse, I was reprimanded and threatened with my license. The large medical centers are not what they should be.

Yikes.

Wow. Life has been rather busy lately. I recently moved, my grandmother passed away necessitating a last-minute trip to the midwest, I'm in the process of starting a business and am chasing after a 16 month old. Oh, you want to see a picture? Ok!

Work has been as busy as ever, with both the regular and overflow units open. Lots of sick people this time of year as usual. Lots of scrambling for transfer orders so that we can get more sick people in. It's a revolving door.

Primarily working weekends, I am more attuned to the Weekend Syndrome now than ever before. This syndrome is characterized by a lack of decision making on the part of doctors who are covering their partner's patients on the weekend. I'm assuming that the covering doctor gets a sign out from the doctor who is off (usually - sometimes not) and they round on the patient over the weekend.

Normal decisions about a patient's care are typically made - adjusting medications and vent settings, transfer orders, that sort of thing. But if you are the patient and you are anywhere near close to death, forget it. The status quo is maintained at all costs. Is it somehow taboo for a covering doctor to make end of life decisions over the weekend? Apparently it is!

My patient, in his 50's or 60's had had a cardiac arrest and thus ended up with the usual trifectic sequelae of shock liver, kidney failure and ileus. Apparently he'd been in CCU for about a week. No family in the picture, and thus no one to make decisions on his behalf.

Of course he was a full code.

Perhaps it was just because I was seeing the situation with fresh eyes, but after looking at his hideously disfigured labwork, it was pretty obvious that this poor guy wasn't going to make it. And yet 5 doctors rounded on the patient, and only one of them was familiar with his situation. The rest were covering for the weekend. Every single doctor looked at the patient, wrote a note, and went on to the next patient.

The next day when I arrived on the unit, I found that his condition has worsened. I figured that withdrawing the vent and CVVH was too lofty a goal, so I aimed to at least change his code status to "no code." If his heart was to stop, I didn't want to have to shock him or do CPR. People who are that sick do not come back from the dead when we code them; or if they do, they certainly don't stay long.

As each specialist rounded on the patient, I informed them of his labs (worse than the day before), his labile blood pressure and the fact that I was needing to go up on his pressors. We were all pretty much in agreement that his prognosis was very poor.

Despite this poor prognosis, each doctor suggested getting a head CT scan. And that is what we did. I still to this day cannot figure out why we did that. Maybe it would have shown a bleed, or maybe it would have revealed that he had cerebral edema. It could have confirmed the diagnosis of anoxic or hepatic encephalopathy. But as the doctors discussed this amongst themselves, it was stated that there was no effective treatment for any of those findings. Oddly enough, although each specialist said that they wanted a head CT, not one of them would order it. It was up to the hospitalist to order it. She knew next to nothing about the patient and when I called her for the order, she could not have cared less about why the other doctors wanted it. "If they want it, go ahead and get one."

When I asked the cardiologist about at the very least making him a no code, he pretty much came out and told me that he wasn't going to do that because it wasn't his patient. I asked if we agreed that the patient was probably going to die soon. He said yes. I told him that I wasn't even asking to withdraw the vent - I just didn't want to code the guy. He flat out told me that it was the responsibility of the patient's usual doctor to make that sort of decision. Everyone concurred. Every time I asked about making him a no code, they all said that it would be addressed the next day... Monday. When the usual docs would be back around.

Meanwhile, my patient required frequent cleaning due to the lactulose he was getting. His blood chemistries were so out of whack that he was literally breathing over 40 times a minute. The highest rate I saw was 47. Go ahead - try to breathe 47 times per minute. See how comfortable it is before you pass out.

Because the usual doctors weren't on, this patient laid in the bed another day. Not to sound crass, but in addition to his probable suffering (I actually don't think he was conscious, but who knows for sure), he was using a critical care bed and his treatment required that he have one nurse to himself. Believe me when I say that many many thousands of dollars were spent on him during that day alone.

Why? Because we were waiting for family to come in from out of state so that they could say goodbye? Because one of his loved ones just couldn't bear to let go yet? Because the doctors truly felt as though he had a fighting chance?

Nope. It was because the doctors who could make the decisions were off that weekend and no one else stepped up. If it happened here, it's happening elsewhere, maybe many elsewheres.

Add it up.

Submitted by My Own Woman:

It was one of those rare nights on midnight shift where the ER was eerily quiet. The quiet and calm doesn't happen often in the ER and the nurses try to take advantage of it when it occurs. After all the supplies were stocked in each room and the trauma carts and the Zoll monitors were checked to make sure all was functioning properly; the nurses sat down together for a rare moment of rest. It was 4 AM, the time on night shift where the wind starts to go from your sail before you catch your second wind about 5AM.

As we sat and talked about non-nursing related things in our lives the Ambulance phone went off. I got up to take the call. "This is A-1 Ambulance. We're bringing in a 20ish year old male with severe injuries to both of his legs. He was hit by a car while riding on the back of a garbage truck. His heart rate and respiratory rate are within normal limits. His blood pressure is slightly elevated and he rates his pain in both legs at a 10 out of 10. He has an IV established with Normal Saline at 100 and we have him on high flow oxygen. We'd like to give some Morphine. He has no allergies. ETA 5 minutes." I relayed the information to the ER doctor who authorized Morphine 2mg IV and we will re-evaluate upon arrival.

The patient arrives to the ER 5 minutes later without any relief from the previous Morphine. His legs are deeply cut and crushed at the level of the knees where the car clipped him while he was riding on the back of the truck to collect garbage. His vital signs were stable except his blood pressure was elevating probably in response to the increased pain. After an assessment by the nurse and the ER physician, Dilaudid 2 mg IV was ordered and given along with some IV fluids. X-ray came to the department for a series of xrays on his legs. The Patient Care Technician came into the room to draw blood and do an EKG. All the while the patient kept asking me if he was going to lose his legs. "Please, am I going to lose my legs? Please tell me." I couldn't answer him, I had no way of knowing at that time but the prospect of him losing his legs was a good probability. He had no pedal pulses and no sensation below his knees. I told him, "I don't know right now, we have to wait to see what the tests tell us." It was an honest answer. He turned to the Patient Care Technician and asked her the same question, she immediately responded, "No, you're not going to lose your legs, quit thinking like that. Everything is going to be fine." I wanted to scream at her but held my tongue and tended to his immediate care.

We cleansed his gaping wounds behind his knees and bandaged them with sterile water and gauze. We gave him repeated dosages of Dilaudid as we prepped him for surgery. It was horrible watching this young man with his whole life in front of him crying because of the pain and the uncertainty of his diagnosis that must surely have been going through his mind. After a short time we shipped him off to surgery and the Emergency Department was relatively quiet once again. We had added a few more patients in the time I spent in this man's room, but everything seemed to be under control.

I couldn't get the young man off of my mind and the scene and conversation I had witnessed between the Patient Care Technician and him. Finally, after wresting with my conscience, I took her aside and told her that telling him he was not going to lose his legs was not a very good thing to do. I told her that she could have very well given him false hope and that is the last thing you want to do to a patient. She apologized to me and told me "she just wasn't thinking."

The night ended without any more trauma and we all went home to our beds. I had the following day off and went about my normal routine. The following day I returned to work and my arm was grabbed by the Patient Care Tech that had helped me with the young man two days earlier. Her eyes were red and swelling with tears. "He lost both of his legs," and as she spoke the words the tears rolled down her face. "They cut off both of his legs, they couldn't save either one of them." At first her words were not registering in my mind until I realized what she was talking about. The young man who she told would be just fine had lost the very thing he was so concerned about and wanted reassurance about. The tears welled up in her eyes more. "How could I have done that, how could I have said everything was going to be ok?" My heart went out to her. In her attempts to ease his mind, she let him down and herself. "How can I ever make this up to him?"

I shook my head back and forth and said, "You can't do anything for him, but you can learn from him and never tell anyone things that you don't know for sure. You learned, and learning is a good thing." She replied, "Yeah, I learned, but I still have both of my legs."

This is a very good lesson. However, I can't help but wonder if despite her comments, the patient really knew deep down that he was going to lose his legs. Denial is a double-edged sword. It can keep one from seeing what's really going on, but it's also a highly effective coping mechanism meant to protect us from knowledge that we aren't ready to process. I doubt that the young man took the tech at her word. I'm not condoning what she did, but really? Truly? Deep down, I don't think he was surprised at the outcome. So tragic. -geena

I know you know that our patient was on isolation, because it's very hard to miss: 1) the big red "ISOLATION" sign on his door, 2) the big cart outside of his room containing gowns, gloves, and masks, and 3) me, standing at the patient's bedside wearing said garb. So when you come in ungowned and unmasked and I say, "Um, you do know that this patient is in isolation?" the correct response is not to hold up your gloved hands and say, "It's okay; I'm gloved up."

When told that this patient requires more personal protection equipment than gloves, the other correct answer is not, "I don't have time to bother with that shit. I'm not touching him anyway." Do you want to know how I know that this answer is incorrect? Because when you were bending over ever-so-slightly to listen to the patient's chest using your own stethoscope instead of the dedicated isolation stethoscope, the front of your shirt poofed out just a little, and just enough to brush the side rail. The side rail that has been touched by many many gloved hands probably containing all kinds of millions of organisms that are, you know, resistant to more than quite a few antibiotics.

And the "I don't have time to bother with that shit" comment? I did point out to you that I have to put on the gown, gloves, and mask every time I walk into the room, which was easily 1-2 times an hour, sometimes more often. For 8 hours. So you do not have to tell ME about what a pain it is to bother with it. I am well aware.

You did get one thing right. As you walked out of the room, you very correctly used the alcohol hand gel... and when I told you that the one of the organisms that the patient has does not respond to alcohol gel and that you need to also wash your hands, your snotty reply of "I know that, Geena" was a little unexpected. If you don't even know enough to use proper isolation technique, how am I to know that you know anything else about it?

And finally, when I remind you to clean your stethoscope, your answer of, "I already did that" is not fooling me at all, because I have been watching you closely out of the corner of my eye and I know full well that not only did you not clean your stethoscope, you handled it after washing your hands, thereby contaminating yourself again. Well, it was going to happen regardless. I wish it hadn't happened before you started putting your grubby hands all over the chart, though.

And although the pen that was sitting on the counter right next to you was my favorite pen, I threw it away after you were done "borrowing" it.

Right before I called the epidemiology nurse and told her alllll about you.

She loves you, yeah yeah yeah - enough to bring the Beatles to Grand Rounds, hosted at Emergiblog! As usual, I'm a day late and a dollar short for the link, and as usual, Kim has done a fabulous job hosting.

There's a post I wanted to bring your attention to, because it is the funniest story I have read in a very long time. There's screaming, pain, and the payoff of a special 8 pound delivery... Disappearing John brings you the tale of a delivery that he was fortunate enough to be involved in. Funny funny funny stuff!