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You may have noticed that I have been away. I’m a Mrs. Geena, RN now!! :-) Not surprisingly, I assumed that I would have just a few minutes here and there during wedding preparations to post story submissions during the time I was gone… And not surprisingly, I found that it was an impossible goal to achieve during all the hustle and bustle. Actually, this blog became lower than the lowest priority. It wasn’t even on the list. :-)

Now that I’m back, irregular posting will resume!

So. Who wants to see a picture?!?

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Hoping This Won’t Be A Mistake

Recently, I took care of a 60ish man who had cardiac arrested at home, with no CPR done until the police showed up ~7 minutes later with an AED. That’s a long time with no oxygen. When I had him, he was on a ventilator and was posturing. It didn’t look good. His family kept talking about the future though (as in, “Dad didn’t talk much about his doctor visits [he was being treated for borderline diabetes] but I guess we’ll be going with him from now on!). I figured that there was no way in the world that this guy would wake up. He was taking breaths on his own, but wasn’t responding.

Neurology was consulted, and we simply waited, doing as much supportifve care as we could. The next day, he was more responsive and was extubated. The day after, he was mostly coherent, conversant, and aware! I was completely amazed and VERY happy. The neurologist came in that night to examine him and sat out at the desk writing her progress note. She was talking about how gratifying it was to finally see a case end up positively.

Now flash back to about 3 years ago. I’d been at my current job only two months and had to admit a young woman that was my age. She had been up on the medical floor with some sort of viral thing, and just simply went unresponsive. No one knew what the heck was happening, only that she was not awake anymore. She ended up staying on our unit for about a month, and in that time got a tracheostomy and a PEG tube. She was eventually sent up to our Sub-Acute unit, which is like a nursing home within a hospital. Most every patient up there is trached on a ventilator and gets lots of rehab, which may or may not be working.

For the last 3 years, I have checked on the computer for this patient’s orders to see if she has gotten any better. She had only been married for about a year; was her husband still with her? Visiting her every day as he had in ICU? 3 years can be a long time. Her prognosis wasn’t the greatest; apparently she had developed some sort of nervous system thing where the myelin sheath of the nerves (the slippery coating that allows impulses to travel so quickly and effortlessly) deteriorated. From what I can tell, she has remained unresponsive and has been getting physical therapy consistently for the last 3 years.

So anyway, this neurologist was at the desk for this other patient, talking about how happy she was that this patient had turned around and said, “Hey, do you guys remember that young patient that was a hairdresser…?” and I immediately said the patient’s name. I had been intending on asking this particular doctor about my young patient for a long time, but just never had. I was VERY eager to hear any news about how she was doing.

Well, this is how she’s doing: She WOKE UP! She interacts with others, recognizes her husband, can move her arms around. She can’t walk, but it’s definitely looking more and more like a possibility that she may be able to in the future. I asked how that was possible and the doc theorized that since she was young, her myelin was able to regenerate itself. Or something. And her husband still visits religiously. I can’t tell you how immensely happy this all makes me. I have no idea why I have thought so much of this particular patient over the years; maybe it’s because it could have easily been me. Or someone I knew. All I know is that some weird thing happened to her, and her life was robbed from her, leaving only a shell, a body. It was so devastating to the family. I can still remember the desperation on their faces every time they’d walk onto the unit, hoping for some change in her condition.

I hope she continues to do well. I hope she can go home someday. But here’s the explanation for the title of this post: This sort of situation isn’t the norm. People who lack oxygen for more than a few minutes usually never “recover.” So my patient who cardiac arrested may have just had barely-perfusing rhythm until the cops showed up. Who knows? All I know is that the typical patient who suffers brain damage from anoxia (lack of oxygen) ends up fairly vegetable-like or very disabled. I have no idea if these two stories will induce “false hope” into someone surfing around who happens to have a loved one who is comatose, but ya know… I have every right to be ecstatically happy that these two patients have at least partially recovered following extenuating circumstances. These two stories are what keep me going. They provide a point to my profession. A reason to keep going into work.

Sometimes we win.

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We’ve added a little feature to Codeblog – definitions! I realize that some people that read this site may be laypeople and might not know what CVP’s or NG’s are. Hopefully, your browser will have dottedly underlined “CVP” and “NG.” If you find a word that is underlined, I have defined it. To get to the definition, just put your cursor over the word and wait a second. The definition should magically appear!

Unfortunately, my very own browser doesn’t support this yet. Apple’s Safari is relatively new, though, so hopefully it will in the future. It seemed to work with Internet Explorer and Mozilla. Let me know in the comments if it doesn’t work for you and what your browser is. Not that I’ll be able to do anything about it, but… I can go ahead and commiserate with you! I’d also love some feedback as to whether it’s helpful.

Lastly, feel free to go to “submit your story” to e-mail me with anything else that’s on your mind. I love to explain things and teach, so although I can’t diagnose or explain your symptoms, I can explain why some ICU’s don’t allow flowers or plants in patient rooms (because we want all the flowers out at the desk where we can see them!) or why gurneys are so uncomfortable (oops… actually I can’t help you out there).

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Erroneously Medicating

Sorry for the lapse in posting. I’ve been busy finishing up wedding stuff and haven’t had time to keep up with codeblog. It’s mostly done now, though, so here I am again!

To those who have submitted stories: I’m not ignoring you! I’ll be gone at the end of October and will be posting them during that time. Thank you for submitting them.

I’m not sure how to describe how it feels to make a medication error. As the old (altered) saying goes: There are two kinds of nurses – those have made med errors and those who will. I’ve made two in my life (that I can remember or know of). Once I gave an extra dose of Lasix because I failed to check the Recovery Room’s nurse’s notes. I didn’t feel that this was my fault, however, because RR RN’s don’t usually give scheduled medications. (It matters not – I’ve checked the RR sheet ever since). There’s a specific MAR sheet that meds are supposed to be charted on, and the RR RN didn’t chart on it…. she charted on her RR sheet. Which is perfectly appropriate. But I wouldn’t have given the Lasix had it been charted on the MAR. Nevertheless, when I realized it, all the blood rushed to my feet and a feeling of utter horror overcame me. Not only did I think of the patient, I was thinking of myself – now I had to call the doc and fess up. How could I do something so stupid?

Fortunately, the MD was already the nicest doc I’d ever met and actually had me give the patient MORE Lasix. Whew!! The other involved Reopro – it’s only supposed to infuse for a specified period of time, and that time came and went for my patient. No harm with that one, either. I called the doc (at 5am… gulp…) and he said it was fine. Regardless, I was still mortified. I was lucky in that the errors I made didn’t result in harm to the patient, and I still learned the valuable lesson that I am capable of making med errors. In school, they make you check and triple check every medicine… being on your own is a real eye-opener.

The other night, I caught a pretty big med error that someone else made. I won’t go into the specifics, but the patient ended up needing dialysis because of it. The patient will be fine and will only need a few treatments, but the nurse who made it has been nursing for much longer than I have. She was crushed when she found out. I would have been, too.

So RN’s and LPN’s… you’ll probably make an error at some point in your
career. Try to learn from it and move on. MD’s… don’t be too hard on us
when we call you with our mistakes. We’re already feeling very low. Each MD I talked to with my errors were very professional and understanding. It helped immensely. Many factors go into an error occuring: the completeness of documentation, current staffing levels, the availability of unit dosing. The RN that made the error resulting in the patient needing dialysis had been on the phone with no less than 3 doctors who kept NOT addressing that the patient’s heart rate was low. This caused her to be late with the medication, which probably caused her to rush to get it administered. She still should have been paying attention, but we’re only human, after all.

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And We’re Back

…back to the pain issue, that is. I had a terribly interesting experience the other night at work. A middle-aged patient came in by ambulance complaining of chest pain. She typically has chest pain due to some heart condition I’d never heard of, but it worsened due to activity. She’s usually treated at another hospital, but the paramedics brought her to ours because it was closer.

When she arrived in the ER, she got the internist on call. No cardiologist, although she has this heart problem. The patient says that during these “flare-ups,” only one drug helps: Dilaudid. The patient is being treated at a pain clinic and is currently on oral narcotics at home, plus a benzo (anti-anxiety drug). The internist refuses to give this patient Dilaudid because she’s being treated at a pain clinic. MD prescribes Morphine, which patient says does not help. Next day, patient gets a slightly more… aggressive nurse, and said nurse repeatedly calls MD because of patient’s unrelieved pain throughout the day.

MD finally relents to one dose of Dilaudid, which the patient says helps. Awhile later, MD comes to see patient, and patient tries to fire MD due to inadequate pain management throughout the night before. MD says she isn’t flustered, but clearly looks it, and when told that it is her responsibility to find another MD for this patient, says that it is not. The MD says it is the patient, who is in an unfamiliar hospital with unfamiliar docs, who is supposed to find her own 2nd opinion.

A cardiologist is FINALLY consulted, and ultimately clears the patient, saying that the echo looks okay. The patient is relieved to hear this, but is still having chest pain, and is not too happy about not being able to get more Dilaudid. Since there is no other MD to call, I call the MD that has supposedly been fired. She still insists on not giving any more Dilaudid, saying the patient is drug seeking. She offers more Morphine, the patient states that MS doesn’t work, and she’s leaving AMA to go to the other hospital.

MD discourages this somewhat, but what can you do? And did I mention that the nurse got to be in the middle of all this? I’m not used to drug-seeking patients. I’ve had only a few. But where they were shaky, manipulative, needy, and had a general desperation about them, this patient had none of that. (Except the MD’s claims of manipulation, that is.) MD insists that the patient is going from hospital to hospital to get pain meds and that it must stop somewhere. Patient states that she has had unrelieved pain for a day and a half, and the MD is negligent. Patient brings up lawyers and lawsuits a lot. She also brings up the competancy of the MD, which I find ways around commenting about. Lots of noncommittal and vague “huh’s” on my part. The patient seems very intelligent, calm, and even though she’s making these “threats,” she isn’t ranting or anything. Is this manipulative? I personally have no idea. It could be taken either way quite easily.

Here’s a kicker for you then. When I went back to the patient to offer some IV Morphine, she was already sitting up in bed, and told me when I walked into the room that she had decided to have her husband drive her to the other hospital. She said the treatment we were giving her was the same treatment she could give herself at home, and there was no point in being here. I said that was fine (she was still calm and matter-of-fact… not overtly angry in any way) and that I’d just gotten off the phone with the MD, who said she could have some Morphine. (Remember… she’d received Morphine all night and claimed it didn’t work). The patient was quiet for a moment, and I asked her if she needed for me to do anything to help her get ready to go. She looked at me and said, “I wish that I would have known you could give me Morphine before I told you that I wanted to leave.”

What on earth am I to make of that? I’m aware that we have our own responses to pain, but she was sitting up, in no obvious distress. She spent the whole previous night complaining that Morphine didn’t work. Why, then, would she get all weird on me? Up until that point, I was on the patient’s side. I thought the doctor was being unreasonable and was sore that the patient tried to fire her. Pain is subjective, and even when I myself was having moderate kidney stone pain, I could have sat up calmly, too. (When it was severe, that was another story… but this patient wasn’t claiming severe pain anyway).

I’m interested to know what other RN’s and MD’s would have done in this instance, only knowing what I’ve described. If I get a few good responses, I’ll post in the comments what I myself ended up doing.

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Absolutely Brilliant

Linked from A Chance to Cut Is A Chance To Cure, is an article written by a doctor who has been on both sides of the knife. It reads really well. Very interesting.

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Why, Oh Why, Are Single Lumen Catheters Even In Existence??

Ok, I came across another one tonight. My patient was admitted through the ER, and in the ER, a single lumen central line was placed.

I get patients from the OR with these single-lumen things as well.

Please, if any surgeons, anesthesiologists, or ER docs read this blog, perhaps you could tell me WHY anyone would go through the trouble of cannulating someone’s jugular vein only to insert a single lumen catheter? Why not just go for the gold and put in a triple?

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I’m not in the mood to think up a title.

“What have the doctors told you?”

“Nothing. They all say they ‘don’t know what will happen.’”

“Oh. The neurologist was by earlier when you were at home. He said that the CAT scan was negative, but that her brain wasn’t receiving much oxygen during the time that her heart wasn’t beating.”

“Really? But… they were doing CPR…”

“CPR is effective, but still not as good as the heart beating on its’ own.”

“Oh, there she goes opening her eyes again. But she doesn’t see me. She just stares. Will she wake up, do you think? You must have seen this sort of patient before.”

<Averting eyes>”The neurologist and I agree that if she was going to recover function, she would have done so by now. It’s been 48 hours since her arrest. Because she has not improved, it’s not likely that she will. She may recover enough to have the breathing tube removed, but will probably remain vegetative. I know that wasn’t the answer you were looking for.”

“But it was a realistic one. No one will give me any answers. I just want to know what to expect here with my mother. I want someone to show me the reality of the situation.”

And so I tried. But then lamely ended it with “But you never know.” Because it is so terribly difficult to deliver news like this. I wanted desperately to make the doctor do it the next day, but that would have left an entire night of uncertainty. Uncertainty can be worse than the reality. Maybe subconsciously there’s an awareness that this isn’t going to turn out well, but there’s still hope, because no one has said otherwise.

Did this man know that his mother wanted to die? That she walked into her dialysis treatment and told the nurse that she had a plan to die? He talked about how he was going to call her the day she cardiac arrested, but didn’t… and now it was too late. He didn’t appreciate her when she was “here.” I tried to tell him not to go down that road… there was no way he could have known what would happen, and that he was here now. What a terrifically intense range of emotions he was feeling. I don’t know how he didn’t crack right down the center with the strength of it all.

About an hour later, his sister joined him at their mother’s bedside. I had been warned by friends of the family that she wasn’t going to take it well. She called from the waiting room and I told her to come in. I met her and her friend at the door. I led them to her mother’s room, trying to figure out if I should prepare her for what she was going to see, but I could tell she wasn’t listening to a word I said. She was desperately looking into every room we passed, trying to see her mom. She’s been away for several years and hasn’t seen her mother in all that time. But when she actually reached her mother, she was calm. She took her mom’s hand and just started to talk to her brother. There were no hysterics or theatrics.

It was a very emotionally exhausting night.

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Problems Problems Everywhere

Just a few things that I had to help deal with or deal with directly last night:

  • Bed 4′s heart rate was >130, blood pressure about 70, and feet were ice cold and pulseless.
  • I ran to the lab to deliver some blood draws for another nurse and proceeded to have to deal with those lab draws for 3 hours after dropping them off. Specifically, they weren’t logged in correctly, and every time I tried to set it straight, I had to deal with a different person, had to recount the entire tale all over again, and ended up with the same result: confusion and passing off of the situation to someone else.
  • Beds 3 and 4 did not receive their TPN (Total Parenteral Nutrition – basically, dinner in an IV bag) until 6pm (it needed to have been hung at 5pm) and one patient ran out (not a good thing). This actually almost never happens, and I did not appreciate having to deal with it.
  • Bed 7 was okay until they started having respiratory distress and a blood pressure of 59.
  • Beds 8 and 9 were new admits of the day. Unfortunately, the part of the computer software that sends registration information to the part of the computer system that we use to enter orders, obtain lab results, chart meds, enter admission information, and pretty much just do everything, wasn’t working. So for those patients, we had to resort to paper. Lab slips for ordering labs, paper for receiving results, central supply slips for ordering supplies, Medication Administration Records for charting meds, IV records for charting IV’s hung, and last but certainly not least, physician order sheets. It was a mixture between amusement and horror that we had to tell every single doctor consulting on those two beds (and there were plenty) that they would have to write out all of their orders on paper. The fun part will be when the system is working again – every single order, lab test, result, equipment/supply charge, med and IV given will have to be retroactively charted. Dear God, please don’t let me have to be there when that happens.
  • Bed 12 was a transfer from another floor and had emergent major surgery, having to come back intubated on a ventilator and needing vasopressors. She has had a long standing history of everything, and even anesthesia had trouble getting a stupid IV line in her. That apparently didn’t prevent them from sending her back to us (intubated and on pressors, I remind you) without a central line. That left us with 2 lines with which to infuse Dopamine, a mainline, a PCA line, antibiotics, and sedation, none of which can go together except the mainline and one other of the above, not including sedation, and requiring the PCA and the mainline to infuse together. Add in that she had typical post-op hypotension exacerbated by the morphine we tried to give her for extreme pain, and it was all that much worse. Also add in that because of her low BP, we were unable to provide enough sedation to knock her out sufficiently so that she wasn’t so freakin’ awake, and you have a patient who is miserable. Oh, you can also add in that her nurse had been gone for about a month and is sorta inexperienced. Oh yeah, and she was in contact isolation. (That would be the cherry on the sundae, for those of you who don’t work on hospital floors.)
  • We were short staffed on night shift. This actually somewhat resolved itself (well, someone else resolved it) but I had to worry about it until then. And even then, it didn’t resolve itself all the way, but we had to do the best we could.
  • Sometimes they test the power. The back-up generators come on, there’s a small flickering of lights, no big deal. Last night, they were doing something different, and 2 times the power went off. But it was different – the monitor screens went blank and the vents, although capable of battery backup, would stay on but alarm a zillion different alarms to tell you that they were on battery now, and the unit’s emergency lights went on, and yes the whole thing only lasted about 4 seconds, but those were the longest 8 total seconds of my life, quite possibly.

Fun, fun, fun all around.

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Sorry for the absence. Nursing hasn’t been incredibly interesting lately.

Another kind of patient that strikes fear deep in my heart are the detox patients. Patients withdrawing from alcohol is not a fun thing to see. When I considered nursing as a career, the image of grown men writhing on a bed screaming, spitting, hitting, and kicking didn’t even occur to me. Neither was I ever exposed to such malarky in nursing school.

I think my very first exposure to a patient that was withdrawing from alcohol was when I worked in CVICU in Illinois. He had had open heart surgery 2 nights prior, and I was assigned to him from 7pm-7am. I’m pretty sure I didn’t leave the room more than once or twice the whole 12 hours. I even had to get and give report to the other nurse in the room. He was insane! I had never had to deal with anything remotely like this man.

Even though he had wrist restraints, it didn’t stop him from wiggling the rest of his body around to put various tubes (chest tubes, catheter, CVP line) where he could grab and pull at them. There was absolutely NO reasoning with him whatsoever. Everytime I’d grab one of his hands to stop him from pulling out his chest tube, he’d squeeze my hand as hard as he could. It hurt, and it made me really angry.

I had mixed feelings about being angry. This patient was half out of his mind, but half in his mind. He had a lucidity about him that infuriated me. He knew where he was and why he was there. Yet he still insisted on pulling at things and hurting me! I was baffled and frustrated. Every time I wanted to leave the room, even if it was just for 1 minute to get a medication, I had to have someone be in the room watching him closely… Otherwise, he’d go for those damn chest tubes, and I was NOT about to call a cardiac surgeon in the middle of the night to tell him his patient pulled his own chest tubes out.

It was one of the most miserable nights of my life. I had no idea what this man’s problem was. A few days later, someone was reading his chart and noted that he “admitted” to drinking a few glasses of vodka a day. Well, there ya go.

Where I work here in CA, things are much different – we’re much more proactive about detoxing people. The thing that’s most different is that instead of incidentally getting an alcoholic that just happens to need ICU care, we get alcoholics in ICU to detox them. We’re the only unit that’s equipped to give someone massive doses of Ativan, Haldol, and Valium sufficient enough to quash the DT’s while also keeping them alive. We’ve had patients on 40mg of IV Ativan per hour for several hours. A typical dose of Ativan is like 0.5-2mg by mouth every 4-6 hours. Mainlining 40mg an hour is some serious business and requires a lot of monitoring.

I never have a good night taking care of detoxing alcoholics. I can never relax. The second I turn my back, they’ve found a way to take out their IV. And although the doc wants them in ICU on an Ativan drip, they also want us to walk the tightrope perfectly, to find the magical dose of Ativan that will both subdue the DT’s while simultaneously making the patient SANE. From a nurse’s perspective, a typical ETOH patient is either crazywackycombative or snowed. There simply isn’t an in-between until like Day 3 of Detox Hell. Sometimes we have to sedate them so much that they require intubation for airway control.

Detoxing can be life-threatening. If you think the mind has trouble giving up alcohol, you’d be right. However, the body itself is also addicted and DT’s are not fun. Uncontrollable tremors, hallucinations, impaired judgement, rage, mood swings, and seizures are all possible. And guess who gets to cope with it all? Not the patient; they’re out to lunch and fairly unaware of what they’re doing. The nurse gets to cope with it. Bleah.

I can’t tell you how many times I’ve been tempted to just slip some gin down the ‘ol NG tube.

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  • profileI am Gina. I have been a nurse for 15 years, first in med/surg, then CVICU, inpatient dialysis, CCU and now hospice. This blog is about my experiences as a nurse, and the experiences of others in the healthcare system - patients, nurses, doctors, paramedics. We all have stories!

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