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Knock, Knock. Who’s There? Asystole.

At work, we have Voceras.  They are little phones that we wear around our necks.  We use them to call each other, other departments, take phone calls.  They were a little annoying at first and kind of hard to get used to using, but now we all use them every day and I personally have found them to be really helpful.  Our unit is large, and instead of walking around trying to find Susie Q RN to tell her she has a phone call, we just click our Vocera button and can reach her instantly.  Easy.

They added a feature a little while ago.  The Voceras now tie in with the patient monitors.  I don’t know how it all works; for all I know, the unit secretary brings out a magic wand, chants a spell, and then the monitor and Vocera both know what patient I have that day.  This results in a couple of things.

First, when MY particular patient puts their call light on, in addition to hearing it throughout the unit, my personal Vocera makes a sound so that I know without looking around that it’s my patient who needs help.  Next, and this is pretty interesting – when my patient has an arryhthmia, my Vocera makes a “do-dunk” sound.  It kind of sounds like a knock.  I look at the little screen and it tells me which room is alarming and what the alarm is.  All very helpful when I’m in my other patient’s room.

So one day, I had a patient that wasn’t doing very well.  We were communicating with the patient’s family and trying to decide whether or not to make him a no-code, or withdraw life support altogether.  It’s an understandably difficult decision to make and the family was struggling with it.  As the day wore on, though, the patient was becoming more and more unstable.  The monitor started alarming, which made my Vocera start doing its “do-dunk” sound when the patient started having bradycardia.  The family still wasn’t comfortable with the idea of taking him off of life support though.

Then it came to be my turn to go to lunch.  We had a break nurse, so she could completely take over caring for my patient and only my patient while I was gone.  I brought her up to speed on the situation.  As I left, I could see the family coming out of the room to talk to the nurse that took over for me.

I went to the cafeteria to get lunch, brought it back to the break room, and started to eat.  I was talking with a coworker about our kids when I heard the familiar “do-dunk.”  But when I looked at my Vocera, it said, “Room 2-0-1-1 ASYSTOLE.”

And that is how I found out, over lunch and lighthearted conversation, that my patient had died.

I told my co-worker what my Vocera said, and without even looking up she replied, “You know, you can push that ‘Do Not Disturb’ button.”

Um… yeah.

When I returned from lunch, the break nurse started to say, “Your patient…”

I just said, “Yeah, I know.”

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The Evolution of Pill Crushing

We have to crush pills sometimes.  Either the patient (through aversion or physical limitation from stroke) can’t swallow whole pills so we crush them and put them in applesauce, or the patient gets their pills through a tube, so we crush them and dissolve them in water.

When I started nursing, we had a mortar & pestle.  (Yes, it’s an affiliate link.  They all are.)

mortar__pestle_large2

Anyway, this is what we used to crush pills.  (Pro tip:  the mortar is the bowl, the pestle is the bat-shaped object)  I always found it very satisfying to fill the mortar with pills and grind them up with the pestle. Of course, we had to then clean both very well afterwards to avoid cross contamination of pills, but overall it was a good system and worked well.  It felt good to crush up the pills and also offered a gratifying CRUNCH sound. Bonus:  Whenever the mortar would inexplicably get separated from the pestle, you could still crush pills!  You’d just take the pill (still in its package), put it on the counter and bang the hell out of it.  A professionally and socially acceptable way to vent your frustrations :)

Cost?  About $10.

Then came along the plastic pill crusher:

pillcrusherThis is a very simple contraption.  You put the pills in, then you affix the top and turn … it’s like a giant screw.  Every once in awhile I’d get the pills in there just right, and would be rewarded with a very lovely CRACK.  Unfortunately, it wasn’t extremely efficient – I’d usually have to unscrew it, jiggle the pills and redo it a few times in order to get them ground up enough to dissolve in water.  Cost?  About $5.

For whatever reason, TPTB decided to do away with the mortar and pestle and pill crusher.  Our then-manager decided to get us something called the Silent Knight.  Maybe the cross contamination became an issue, I don’t know.  But with this device, you would put the pills in a plastic pouch and crush them.  You’d then dump the crushed-up pills out of the pouch into a med cup, mix with water, and viola!  The only clean-up involved was throwing the pouch away.

SilentKnight

This device was pretty handy, I guess.  No pleasing cracks or crunches, unfortunately, either tactile or aural.  Cost: about $90, and from what I’ve seen, pouches are about 5 cents apiece!!  Doesn’t seem like much, but it adds up, and keep in mind that the pouches end up being one more thing taking up space in the trash.  Boooo!

Recently, a new contraption showed up in our med rooms – the First Crush.

FirstCrushwithCups

Now we’ve gone completely automatic!  You put the pills into one cup, put the second cup on top (so that they nest, not form a dome) and put it in the machine.  Then you choose the desired level of crushedness (“standard” or “extra grind”) and press a button.  It then whirs into action!  Whereas the Silent Knight is, well, silent, this machine isn’t very quiet at all – you get all kinds of cracks and crunches and machine-like sounds.

It’s very efficient, but also a bit wasteful as well.  You can add water to the bottom cup containing the pill powder and use that instead of the medicine cup, but you just throw away the top cup, which is wasteful.  The bottoms of the cups are “wavy” and the pill powder often gets stuck in the waves and it takes awhile to stir it all up.  The cups cost about 5 cents apiece, and you need to use 2!  If it were just one, it would be okay since you would have had to use a med cup anyway.  Cost: About $200-300 plus the cost of cups.

So we’ve gone from the mortar and pestle, which is cheap, immensely satisfying to use and creates no extra waste, to this electric machine that’s a whole lot bigger, a whole lot more expensive, and creates a whole lot more waste.

WTF?  If they’d kept the mortar and pestle in the med room, I’d just continue to use it, but they got rid of it!

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Making The Call

A patient codes.  Almost simultaneously, a multitude of actions are set in motion.  When the nurses and therapists at the bedside know each other well, it’s almost like a dance, everyone moving fairly gracefully around each other and the equipment flooding into the room.

Someone watches the monitor, someone makes sure there’s a line and starts one if necessary.  Others give meds, record events, defibrillate, bag the patient, do CPR.  Someone is sent out to call the doctor.

Once the dance is well established, once we are in the middle of doing everything, someone always throws out the suggestion, almost as though it were an afterthought – “someone needs to go call the family.”

During one code, I was the runner.  I didn’t have a specific job; I was just running to get supplies as needed.  After I’d run to get suction tubing, more paper to record on, this, that and the other thing, I was just watching and waiting to see if anyone needed anything else.  Although what was happening was very sad, I was admiring the dance.  Everyone there that day knew each other very well and it was especially graceful.  Which is why when the suggestion was uttered, I was the one available to do it.

Would you believe it?  After over a decade of being an ICU nurse, I had never before been the one to make The Call to the family.  Do I call and be vague?  “Hi, this is the hospital and your mom has taken a turn for the worse.  You need to come in right now.”

“Oh no!  What’s happening?  What’s going on there?  Is she okay?”

“Just come in.”

I don’t really like that approach.  The unknown, in my opinion, is often more stressful than the known, even if it’s bad news.  I think the prevailing explanation was that giving someone such awful news would result in them driving to the hospital at break-neck speed, possibly creating a higher chance of getting into an accident due to being so distracted.

I think that chance exists whether the family knows the details or not.

So I told them that their mom had taken a turn for the worse, that she stopped breathing, the nurses and doctors were trying to help her, and they needed to come in right now.

The patient was sick, but as far as I know wasn’t expected to die anytime soon.  Still, the family member I spoke with took it better than I had expected.  I’m not sure what I was expecting – for them to exclaim “Oh my God,” drop the phone and leave immediately?  Hysterical questioning?

In fact, the person I spoke with was so calm that I wasn’t sure I was conveying the gravity of the situation.

“I don’t know if she’s going to survive this.  Please come as soon as you can.”

“Okay, we’re coming.”

And thus ended the call.

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Perspectives

Not so very long ago, I took care of a rather young patient in her 30′s.  She had a respiratory illness that quite frankly baffled us.  We couldn’t figure out exactly why someone so young and healthy was being completely knocked on her butt by a pneumonia.

The illness progressed to the point where she required bipap to help her breathe.  This is a conforming mask that goes over the mouth and nose and gently (?) pushes oxygen into the patient’s lungs.  It’s considered non-invasive and is something we typically try before intubating patients.  Although most patients tolerate it fairly well, I know it’s uncomfortable.  It can be difficult to put the mask on the patient and achieve a good seal so that no air escapes around the mask.  For this reason, we don’t take it off very often – just to do mouth care, give meds, sometimes give a meal if the patient is up to eating.  Some patients can’t even tolerate coming off the mask to eat more than a few bites of dinner.

So my rather young patient was experiencing what it was like to have a bipap mask on to help her breathe.  I know in some ways it was giving her a break since she didn’t have to work so hard to breathe, but in other ways it was pretty bothersome.  When I was getting report, the nurse told me that the last time they’d tried to take the mask off to give her a break she only lasted a few minutes before becoming short of breath again and dropping her oxygen sats.

So it was with an inward sigh that I explained how breakfast would go.  I told her we could take the bipap mask off for her to eat, but that I wanted her to hold an oxygen mask over her nose and mouth between bites.  She readily agreed; I think she would have done almost anything to get the bipap off.

Breakfast came and I got her all set up.  The respiratory therapist (RT) got the bipap machine off, and we gave her a regular oxygen mask.  I didn’t have high hopes that she would last very long off the bipap and watched her very carefully from my desk across from her room.

She was very good about using the plain oxygen mask between bites.  She lasted 5 minutes, then 10, then 15…. a half hour later she was still doing great just using the oxygen mask.  I was thrilled!   I went in and told her that she could just keep using the plain mask but to let me know immediately if she became short of breath.  I told her I’d be watching her oxygen sats and if they started falling, she would go back on the bipap immediately.

To my complete and utter surprise, she lasted through lunch!  After lunch I could tell she was pooping out some, even though her sats were holding just above where I wanted them.  I told her I thought she should go back on bipap and rest over the afternoon.  She somewhat reluctantly agreed.  I was personally delighted with how long she lasted and told her and her parents that it was very encouraging that she did so well for so long.

About 20 minutes later, I was sitting out at the desk when I saw the patient’s mother come out looking a bit dejected.  I wondered if my patient was okay so as she walked by I asked if she needed anything.  She replied that she was just a little sad and I was genuinely curious as to why.  So I asked, of course.

She replied that she had been so encouraged throughout the day while her daughter was off bipap, and now that she was back on it, it seemed like a step backwards.  It was her 30 year old baby sitting in that bed and she was very understandably worried about her.

So while I was inwardly (and a bit outwardly!) cheering that my patient lasted a good part of the day without bipap, my patient’s mother was very dismayed about the same event.  I tried to tell her that her daughter was doing great, better than I could have even hoped, and that seemed to mollify her a little.  It just never would have crossed my mind to be sad about the whole thing.  I’m glad she came to talk about it.  It definitely provided a different perspective.

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The Kidnapped Napper

My patient’s daughter had been up all night in the ED with her mother and by now it was just after noon.  She was very tired.  Nonetheless, I needed to find her to ask an important question.

I got to the waiting room and found approximately 10 family members, but not the daughter.  I asked where she was.

“We aren’t really sure.”

I thought this was a strange response.  Not only was she a nurse, but the person I wanted to speak with knew the patient best out of everyone there.  She just wasn’t the kind of person who took off without telling anyone where she was going.

“Ok… ?”  Then I just stared at them all, because sometimes that will elicit more of a response.  People don’t like being stared at blankly.

“The doctor told us that he took her somewhere to rest, but he said that we had to leave her alone, and he wouldn’t tell us where he took her.”

Hearing “we think she ran off to join the circus” would have been only slightly more surprising.

I went back to the nurse’s station and related my story to some other nurses working with me that day.  We were all quite puzzled and just a tiny bit amused. As it happened, the doctor in question showed up at the desk and I told him that I had something important to discuss with the patient’s daughter and would he mind, please, letting me know where he stashed her?

He said he would not do that.  He said she was tired and stressed by her mother’s condition and needed rest.

Well, yeah, but I really needed to know if the patient had had the flu shot this season, lest I be reprimanded over not providing a complete admission record.  (Not really, but I did need to know something rather important.)

He said she’d be there in a little while.  About half an hour later she appeared in her mother’s room.

Her family thanked me profusely for “finding her.”

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A Rambling and Some News and Some Other News

I took care of an elderly man recently.  He’d been dealing with multiple medical problems for almost 30 years.  Despite being in some very significant pain, he still made eye contact, still said “please” and “thank you.”

He wasn’t faking the pain.  He was very stoic, but I could tell he was hurting.  That tight-lipped grimace, the tachycardia, not moving a muscle unless it was absolutely necessary.  Still, manners prevailed.

My colleagues and I went above and beyond for him and his family.  There’s just something about being polite to others that makes those others want to help you and help you and help you some more.

I’m not saying that we don’t want to help those that aren’t overly polite.  It was just nice to be treated, well, so nicely.  I wouldn’t expect everyone in severe pain to maintain such decorum.  Every once in awhile you just click with a patient and it makes being a nurse so enjoyable.

So!  News #1.  Another of my posts has made it into a book.  It’s called “Lives in the Balance” and was edited by Tilda Shalof, who has written quite a number of books about ICU nursing.  I have read some of those books, so when she personally asked for one of my posts to be included I was quite flattered!

I’ve read the whole book, which is full of very compelling stories written by nurses who work in ICU.  I highly recommend giving it a read, and not just because one of my little posts made it in!

News #2 will only be news if you don’t follow me on Twitter or Facebook.  I am just over 10 weeks pregnant!  We are over the moon about this and can’t wait to meet him or her in late July.

And I guess the bonus news is that this blog is 7 years old this month :-)

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Choose Wisely

He knew she was angry with him.

“Whenever I come to see her, I reach out and take her hand, but she looks away.”

Husband and wife for well over 50 years, they had been through a lot.  They met in another country in another time, and to hear him tell it, it almost seemed fated that they’d end up together.  Since then, they’d moved many times, raised a family, supported each other through myriad illnesses.  They were growing old together.

Unfortunately, “growing old together” doesn’t always work out like we hope it will.  Diseases and illnesses ravage our bodies; dementia ravages our brains.  She’d long ago given up on their little garden in the backyard.  It was her favorite hobby, but she couldn’t manage it anymore.

She had dementia, and she weighed less than 100 pounds.  Though not a result of her dementia, she was unable to eat properly and had slowly grown smaller and smaller.

She had done all the right things.  She was a nurse and she knew how these things could go.  She had an advanced directive filled out; not only signed and dated, but specific treatments and procedures were addressed – feeding tubes, antibiotics, tests, organ donation, resuscitation – really almost everything you can think of.

Many people designate a DPOA – Durable Power of Attorney – along with filling out an Advanced Directive form.  When in a condition where making one’s own decisions is impossible, a DPOA is a person chosen by the patient (in advance of illnesses and while the patient is considered competent) to make decisions for them.  The hope (for us, as healthcare workers) is that the patient has had a long, frank discussion with their chosen DPOA as to what their wishes are.

In her case, although they may have had this talk, her wishes were also explained in great detail in a written document.  A document that we had a copy of in her chart.  A document that her family readily provided to us.

In the condition she was admitted in, she would need IV fluids, antibiotics, x-rays and tests.  She wasn’t completely unconscious, but she wasn’t very coherent either.  Add in her element of dementia, and it was clear that she wasn’t able to make decisions.

Her family waited quite awhile to bring her in.  They were managing her pneumonia at home until she started having trouble breathing.  That is when they brought her to us.

And this is where she and I met.  They only thing she would say to me is, “I want….” but would never finish the sentence.  She seemed to really want whatever it was and I hope I was able to provide it with everything I tried.

Her husband came in to see her, and this is when we had our conversation.  He told me that he knew she didn’t want any of this.  Definitely did not want a feeding tube, but that’s the direction we were going to have to go in in order to treat her.  He said that he knew she didn’t want it, but that he was her Power of Attorney, and it didn’t matter to him – he was going to ask us to give her one anyway.

It was obvious he was grieving and in denial.  There was no malice, only a very matter of fact manner.  And a deep underlying sadness.  It appeared to me that he was simply unable to carry out that which she had painstakingly directed.

He assumed that this was the reason for her anger; the reason that she wouldn’t look at him anymore.  She had trusted him not to put her through this.

I sometimes take care of patients that are clearly terminal.  They often don’t have their wishes written out in a detailed manner; many people don’t even understand what we as medical professionals are capable of doing to them to keep them alive.

My patient knew.

But she chose a person who was unable to follow her wishes when the time came to actually make the heart-wrenching decisions.  We assume it’s our spouse or closest family members who would be our best advocates, but sometimes that isn’t the best way to go.  Of course, then you are stuck choosing someone that will have to go against your family at a most critical and emotional time.  Do you know anyone strong enough to advocate for you?  To make sure your wishes concerning end of life care are honored?

I very gingerly tried to get him to tell me why he would go against her wishes, but he wasn’t able to give me a straight answer.  I could tell that he already missed her so much.  I hope she can forgive him.

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Jade is not just a gemstone

Just over a month ago, our unit had several H1N1 flu patients.  And they were sick.  Really really sick.  They were also fairly young – 30′s to 50′s.  I wondered at the time why the media hubbabaloo about the flu had died down when I was seeing more and more patients in my unit who had it.

Last time I worked there was only 1 flu patient and they weren’t too sick (yet?) to require a ventilator.  I was really glad to see the decrease in this particular patient population.  I won’t lie – it’s frightening to be a nurse caring for someone with a highly communicable disease.  Masks, gloves, gowns are all provided by the hospital, but I can’t ever shake the feeling that I’ve somehow come in contact with it despite these precautions.

And what of the times that we admit patients and don’t know they have a communicable disease?  At least one coworker I know of contracted H1N1 from taking care of a patient who had it before we knew they had it.

I’m sure she was quite shook up – every single patient who turned up positive for the flu in our unit in that time period ended up literally fighting for their lives on a ventilator.

The most harrowing patient we had was a woman in her 30′s who was pregnant.   Like the other patients, every time she coughed on the vent, her oxygen saturations would decrease to the 80′s and would take a long time to come back up.  Unlike the others, though, she was so fragile that sometimes merely coughing on the vent caused her to go into asystole.

I’m somewhat jaded about coding people at this stage in my career.  I remember, as a brand new ICU nurse, talking to a well-seasoned ICU nurse.  She said that hearing “code blue” being announced overhead didn’t give her any kind of adrenalin rush anymore.  At that time, I couldn’t imagine being in that frame of mind.  Being new, I was expected to go to every code blue that was called so as to get experience.  My heart started going into SVT at simply hearing the word “code.”  If the word “blue” came after I practically had to defib myself before running off to defibrillate the patient.

I eventually got to a place where I could fairly confidently go run a code without freaking out.  I’ve been an ICU RN for 11 years.  In those 11 years, there have been some awful codes.  Two stand out in my mind, and the absolute worst was on the pediatric floor.  When I heard “code blue, pediatrics” overhead, my first (naive) thought was, “little kids code???”  My second thought was to wonder if it was really an adult overflow patient.  Sometimes the gyne surgeries went to the pediatric floor if there was no more room on the surgical floors.  You know, maybe one of them got a little too much morphine and the nurse called a code.  A little Narcan, a few bagged breaths and everyone would sigh with relief and go on with their day.

No such luck.  After running full speed up 3 flights of stairs, I arrived at the room that had the most people spilling out of it only to find a bald, thin 5 year old in the bed.  I thought I was going to be sick.  PICU nurses – bless you all.  I could not do that for any length of time.

She didn’t make it.  Having been a nurse for a couple of years at that point, my naivety about the world already had a few chips and cracks in it.  But on that day a huge chunk fell out.

Since then I’ve come to be more like that seasoned ICU nurse that I spoke with so early in my career.  Along with the semi-jaded “oh crap, a code blue” comes a confidence in one’s abilities, so it’s not all bad.

However, watching that woman go into asystole, knowing that we would have to crash c-section her if she stayed in it?  That took me back to the days when I was new and inexperienced.  I’ve never seen anything like that happen.  Although I was perfectly comfortable with my (pre-arranged) personal role, the overall situation would be completely new to me.

Although HIPAA prevents me from saying much more, I will say that I did not have to experience that situation; not because I was off when it happened but simply because it never happened.

If it had, it surely would have made my top 3.

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For the Record

This story was related to me from a coworker:

I was taking care of a man who was on bipap.  (Bipap is a form fitting mask that goes over the mouth and nose to help augment breathing.  It has successfully been used numerous times in place of intubating patients and putting them on ventilators.)  He was becoming restless and tired of the mask.  I had to wait for the doctor to come and see him, though, before I could remove it.

Due to his medical condition, it was very important that he get an aspirin that day.  Since I couldn’t give it to him by mouth (because of the mask), I had to explain to him that I’d need to give it rectally as a suppository.

He nodded his consent and I proceeded to give the aspirin.

A short while later, the doctor came to see the patient and agreed that we could take the bipap mask off for awhile.  I happily entered the patients room to take the mask off… and before it was even off his face, he stuck his finger in the air and said,

“FOR THE RECORD, that is a hell of a way to take an aspirin!!”

It’s a hell of a way to give one, too.

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Blissfully Unalerted

A few years ago, my hospital updated our computer charting/order entry system.  When a doc orders a med, the system is set up to make the order expire in a set period of time (2 weeks, for example).  During training, we were taught that when it was getting close to the time of expiration, an alert would be sent to nursing and to the doctor who ordered the medication so he/she could renew it if they wanted.

I never agreed with sending the alert to nursing.  I’ve always thought it should just go to the doc that ordered the drug.  Why create a middle man?  Anyway, I almost always ignore these alerts since I know the docs see it too.  They’re really annoying because they pop up randomly even if you are in the middle of something and you have to acknowledge it before you can continue with your task.

We are now upgrading our system and I recently had to go through another training session.  The instructor told us that this new upgrade still has the feature as described above, except for one thing – doctors would no longer receive the alert.  The medication expiration alert ONLY goes to the nurse.

Me:  “Why won’t the doctors be receiving the alerts anymore?”

Instructor: “I don’t know.  Maybe they complained about it enough to have it removed.”

Me (smiling):  “So if we nurses complain about it enough, we might be able to get rid of it too?”

Instructor:  “No no no… no one listens to nurses.”

I would have dismissed it as an offhand comment if it hadn’t been delivered with an utterly absolute lack of humor.

I realize that as annoying as those alerts must be for me, they must be extremely annoying for the doctor.  I only receive one or two a shift, but they must receive numerous alerts throughout the day.  Still… what am I supposed to do?  Drop everything and call the doctor everytime an order for the patient’s stool softener is about to expire?  Wouldn’t repeated phone calls from nurses be WAY more annoying than clicking a few screens?

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Author

  • 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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