This is a very very long post. It details the first 5 hours of a 12 hour shift. Things were especially frustrating on this day.
I had two patients, both of which I had had the day before. Patient 1 is a 300lb. woman in her 40′s with multiple medical problems. By this point, she was on a ventilator in a coma, had a history of spiking temps to 107, was on 70% oxygen with 10 of PEEP (5 is normal) and sats in the low 90′s. We were basically keeping her alive until her grandmother could get there that evening. Patient 2 was a man in his 50′s with an infected toe. He came to us in CCU because his BP in the ER went to 70 one time, which made the docs worry about sepsis. Every vital sign that he had taken in CCU was normal and stable. Prior to admission the day before, he had been independent at home and had a job.
7:45AM: I have 10 medications due for my comatose patient at 8am. Yesterday, I had problems getting one of those meds from pharmacy. Today I check early – it’s not there! I go to the computer and re-order the medication. I mount my patient’s EKG strips and organize my day.
8AM: I check for the med – not there. Okay. I hang/administer the other 9 meds. This takes me 1/2 hour, as the pills need to be crushed and dissolved, other drugs need to be drawn up and pushed slowly, etc. It also takes longer because the stopcock on the patient’s NG tube is cracked and leaking. Got another one and changed it out. Also, the tape on patient’s nose keeping the NG tube in has come off from sweat. I change that after struggling with the old tape – the nurse who put it on didn’t fold over the edges of the tape, so it was all stuck together. I have to be careful tugging at the tape so I don’t pull the tube out of the patient’s nose.
8:30AM: I check for the 10th drug. Not there. I call pharmacy and ask where my drug is… they say that it’s a once a day drug. Yes, I know this. It’s due once a day at 8am. I tell them that this is the 2nd day in a row that the medication has not been available for me when it was due. They say they’ll make a note of it, and they’ll mix it up right now. This is fine, except that the purpose of re-ordering the med in the computer was supposed to take the place of this phone call.
8:35AM: I get the call that nuclear medicine is ready for patient 2. I get the gurney to get the patient on it to go down for this test, after I’ve paged the doc (twice) to get orders for him to go unmonitored (he’s very stable). I do this because I know that the flex nurse that must go with monitored patients is very busy and it will take much longer to arrange for her to come.
8:40AM: Transporter (in record time) is waiting here for my 2nd patient, who has decided that he has to use the urinal right now. I beg the transporter to stay and wait a few minutes – transporters in our hospital are very very busy and in demand. They usually won’t wait more than a minute or so. If you aren’t ready, they leave and you have to call again. This can take up to 30 more minutes. I don’t want my patient to be late for his test, so I tell her it will only be 3 minutes, hoping that he can pee fast.
8:41AM: I check for patient 1′s med in the tube delivery system – I find that the delivery system is not working right now. Great.
8:42AM: I check on patient 2. Still peeing. Transporter still waiting.
8:43AM: I check on patient 2. Done peeing. I quickly unhook him from the EKG leads, BP cuff, O2 sat probe and IV and ask him to move over to the gurney. I am trying to be fast.
8:45AM: I tell the transporter that patient 2 is ready for his test. She asks where the transport sheet is (yes, another sheet to fill out). I hurriedly fill one out and tell a coworker that I am going to the pharmacy to get my medication for patient 1.
8:53AM: I return, distribute 3 other meds to other nurses that the pharmacist has asked me to bring over, then hang my 8AM med one hour late. This means that my 9AM med will be late, which means that my whole morning’s IV meds will be off. Get patient 2′s breakfast off the cart and put it in his room before someone takes the cart back to the kitchen with it still inside.
9:00AM: Patient 1 has an insulin shot due. I check the fridge for insulin – we usually have several bottles of each type of insulin open because people take them into the rooms, someone else needs the insulin and since it isn’t there, assumes that the bottle is empty and opens another bottle. Yesterday, there were two 1/2 filled open bottles of Aspart insulin either on the counter or in the fridge. It can take a week or so to deplete insulin bottles. Right now, there is no Aspart to be found. Re-order Aspart from pharmacy. Patient’s blood sugar is over 300. Oh yeah, tube system still down. Damn. Check with other nurses to see if they’ve used Aspart recently. None have.
9:05AM: Second trip to pharmacy today. Why do I go myself? Well, it’s true that the pharmacy can call transporters. Transporters, as I said, are very busy and it can take 30 minutes for them to bring something over from pharmacy. I’m already feeling behind and don’t want to wait that long, as I might get distracted with other things and forget altogether.
9:07AM: I get to pharmacy. I tell the person helping me that I ordered Aspart insulin and am here to pick it up. She gives me a quizzical look (like I said, we usually have several bottles of each type of insulin around) and asks if I checked the insulin bin in the fridge. This is where I start to lose it a little bit. Yes, I say in a controlled voice. Of course I checked. There isn’t any there.
9:10AM: I give my insulin. Patient 1′s temperature is about 103, and I check the cooling blanket that she’s laying on. Did I mention that she weighs 300 pounds? The blanket is warm. There is no cool/cold water circulating. It might be because the nurse before me didn’t clamp the blanket before putting it under the patient. The patient’s weight will have pushed all the water out and seeing as how she weighs 300 pounds, it’s not going to refill until I take it out.
9:15AM: Patient 2 is back. I get him back into bed and hook him back up to everything (EKG monitor, O2 sat probe, BP cuff, IV) myself, and take his temperature. Get him set up for breakfast. Patient reminds me that he is lactose intolerant, and there is milk on his tray, despite the fact that I entered in TWO places that the patient is lactose intolerant yesterday when I admitted him. Get him juice instead. Give his meds, give his insulin.
9:35AM: I manage to find 2 other nurses to help me roll the patient over so that I can take the blanket out. One of these nurses can’t lift more than 25 pounds due to a recent injury. She’s the one that takes the blanket out. Now free to fill up, we watch it. Nothing. No filling.
9:37AM: Order new blanket and new cooling machine, just in case.
9:40AM: Give rest of 9AM meds. Think back to yesterday when patient 1′s potassium level was low. Realize that I just gave 80mg of Lasix and no one had ordered a chem panel for this patient this morning. Order it myself, draw it up and send it to lab. This takes several more minutes than I had anticipated because the blood flow through the catheter is very sluggish. Thank GOD tube system is now working and I won’t have to have it hand-delivered. I get another nurse to lift up the fat folds on patient 1 so that I can put anti-fungal powder there so she won’t get yeast infections. There is no way that I can lift her pendulous belly, arms, and breasts myself with one arm and put the powder on with the other … I will surely hurt myself. I’m not being mean, I’m being realistic. The little, tiny hole on the top of the powder bottle won’t let any powder through. I stick a needle in it – it’s not clogged. Still, every time I squeeze, only a few faint puffs come out. I get a pair of hemastats and jam them into the hole. Ahhhhh. Much better. Powder everywhere!
10:00AM: Time for patient 2′s pain med. He’s been asking for it for an hour, but it wasn’t due until now. Had no time to call the doc and ask for more frequent dosing. Patient 2 was not in that much distress; he said his toe only hurt when he moved it. I give the med.
10:15AM: MD decides he wants a cat scan of patient 1′s head. I tell him that when we had her laid flat to get the cooling blanket out, she turned a bit purple. He wants me to show him. I put the head of her bed flat again, she turns a not-as-dark shade of bluish. He tells me to get the scan. (You have to be completely flat for several minutes to get a head CT.)
10:30AM: Put in order for CT of the head. Get potassium results back – ACK! K+ level is 2.8. Very low. Start replacing potassium via IV. Check on patient 2, as he has put his light on. He wants the dressing on his toe changed. I take off the band-aid and put another one on it. He asks why I did not clean out the 1cm x 1/2 cm wound. It had been draining, yes, but I didn’t feel as though I had time to sit there and irrigate it. I feel guilty, like I’m neglecting him or something, so I say I’ll be right back.
10:45AM: Return with towels, irrigant, dressings. Take off band aid, irrigate wound with saline, dry it gently with sterile gauze, apply dressing.
11:00AM: I call the CT scanner for patient 1 to set up a time for her scan. They say that they have a patient on the table, but I can start getting her ready and that I should call them before she leaves the unit. I am used to dealing with PM scanner techs, and we have an understanding that when they say get the patient ready, I am going to start assembling several people: 2 Respiratory Therapists (RT’s) – one to bag the patient on the way over, and the other to take the vent to the scanner and get it set up. I need to call the flex nurse (“flex”) to accompany the patient, as she is critically ill and needs monitoring. I cannot go myself because I have another patient. I get a portable monitor and the flex nurse shows up. The flex and I transfer all of the monitoring boxes from the bedside monitor to the portable. I stop the patient’s tube feeding and flush the tube. We disconnect other various tubes and wires.
We call transporter to come and help push the bed – they say that they’re on the way. The RT’s were eating lunch, but came up anyway to take this patient to CT. I call the CT scanner and say that the patient will be over just as soon as transport gets there.
The tech says that there is still a patient on the table. How much longer, I ask? I have coordinated 3 other people (with a 4th on the way) because you said to get her ready. The tech says it’ll be another 25 minutes. 25 MINUTES??? I have to tell 4 other people that they have to wait another 25 minutes, especially when 2 have left their lunches to come as soon as possible? It seems like an eternity. I tell the tech that the other tech said to get the patient ready and call. She said no, the other tech said to get the patient ready and call to see if we could come then. I am livid. LIVID! She KNOWS how difficult it is to arrange to take a critically ill patient to CT. I hang up on her.
11:20AM: I tell the flex nurse that the tech wants him at 11:45AM. The flex tells me that’s probably how long it will take transporter to get here. (ha ha) I intuit that that will not be the case. I go to the other side of the unit to get a dressing change kit and see a transporter walk up (really on the ball today, those transporters) and ask the secretary who paged them. I see that there’s a patient on this side that needs to go to another unit, but the nurse says she isn’t ready; she doesn’t know who called. I ignore the situation thinking it will buy me time. Yes, I’m not proud of it, but I was prepared to blame the delay on the transporter rather than tell the RT’s that they had to wait another 20 minutes, when they could have finished their lunch. I knew the flex would take the patient early, where the patient would sit out in the hall being bagged. I just didn’t feel right about it; I felt better having the patient wait in our unit.
11:30AM: I sit down for 3 minutes and catch up writing my vitals.
11:33AM: The flex nurse re-pages transport. I did not tell her that they had already been here. She specifies this time which room to come to.
11:38AM: Transport shows up. The patient is ready to leave. I call the scanner to let them know that the patient is coming NOW. I am feeling sheepish since the last time I talked to her, I hung up on her in frustration. They don’t answer. I let it go – there’s nothing I can do now. The patient will just have to wait in the hall, being bagged and monitored, until the patient on the table is done.
11:40AM: Sit down to chart my assessments (yes, at some point I did manage to listen to lung and heart sounds, etc. on both patients).
11:45AM: Patient 2 puts light on. His urinal needs to be emptied. I go to empty it and he says that he spilled some on his sheets. I realize that it must not be an easy feat using a urinal in bed (it hurt his toe too much to stand to use it), but if 100′s of other patients can do it without spilling, why can’t he? I admit that this is going through my head and probably shows on my face. I empty the urinal, noting how much was in it, then go get new sheets. I pull the curtain and tell him to roll over. A little more, sir. Ok, a bit more, please. (GOD! TURN ON YOUR SIDE!). Ok, now turn the other way, there will be a bump where the linen is folded over. Great. I start to walk out and the patient calls to me. I turn around and his hands are up. I look at him, realizing the second before he announces it that he wants to wash his hands. I think soap and water will be messy in bed, so I go and find some of those antiseptic towelettes that come on the patient’s food trays.
I find one and take it to him, opening it for him, and he says, “What is this?” I say it’s antiseptic, to wash his hands with and hand it to him. He reluctantly takes it and looks at me like I have 3 heads. I say What? He says in his best “Well, duh” voice: “I need to wash down there, too.”
(Side rant:) Ok, forgive me, but in 7 years of nursing (ugh – actually it’s almost 8!), I have had very very few male patients ask to wash themselves down there after peeing. That’s just how it’s been. Females almost always want to, but males.. not so much. I do realize that he spilled some. I still have patient 1 on my mind, wondering if she’s about ready to code in the scanner while being flat, thinking of all the meds I have to chart, the assessments I have to chart, and yes, I was thinking that I wished the aide was there, but she wasn’t.
This was probably somewhat reflected on my face. It was sort of the last straw that was precisely placed on a pile of a whole bunch of other last straws. There was just someting about the way he looked, the tone of his voice… I felt like a handmaiden. Even so, I turned and went to get him some washcloths. I went into the room, straight to the sink and held my foot down on the pedal until the water that came out was very warm. I put soap in two washclothes, plain water on the other two, and had a dry towel. When I went to give these items to him, he was looking straight at me (NOW the aide is in the room, preparing to test his blood sugar) and said,
“Have I done something to make you so cold and uncaring towards me? All of my other nurses [He'd had ONE other nurse, overnight, and yes - she's probably a pillow-fluffer] have shown me such caring, but you are so cold.”
This statement was met with stunned silence on my part. I had answered his light every time within minutes of him putting it on, instead of waiting for the aide to get it, like many other nurses do. In between coordinating all of the SNAFU’s with patient 1, I had gotten him his pain med on time, gotten him to his test on time, gotten his meds into him on time, and changed his dressing, which is NOT something that needed to be done right then, especially in light of my other patient, who’s temp was up, who’s cooling blanket was on the fritz, and who’s sats weren’t the greatest on (now) 100% O2 with 10 of peep. I had brought him several warm blankets when he was cold. I made sure his breakfast was there when he got back. I did all of this between dealing with Patient 1, AND patient 1′s family, who understandably had a lot of questions.
I finally managed to stammer that I was sorry he felt that way, but that my other patient was very busy, and….
And then is when I plopped his damn washcloths down and walked out. I never went back in.
I told the charge nurse (through tears) that I needed to switch assignments and told her what he had said. It HURT. Right after that, I went into the bathroom and cried for 10 minutes. When I came back out, I found that my coworker was totally willing to swap one of her patients for mine, and we did just that.
I was very grateful.
12:15PM: Patient 1 is back from the scanner. Although the head of her bed is up, she is purple. Very, very purple, with bloodshot eyes that are bulging out of their sockets. Still comatose, she’d had her eyes open for days. Every hour or so, I’d put artificial tear drops in to keep them moist.
We got her hooked back up to the vent and had to switch monitors back, and plug in all of the other stuff. By then, I’d gotten a new cooling blanket and machine and got that back on her (not under her; not enough nurses around at that time to help me roll her.) Gave her Tylenol and had the aide do her blood sugar. Covered that with the insulin that strangely cloned itself in the last 3 hours – there were now 3 open bottles of Aspart insulin on the counter, 2 of which were half empty. I hope they had a nice time wherever they were when I needed them before. Hung more potassium, hung antibiotics.
1:00PM: I have finished charting now. My charge nurse tells me that I have to transfer the patient that I have just swapped for to the telemetry floor.
I get his belonging sheet checked off and get him in a wheelchair (small miracle that one of those were available) and get him to the other unit after calling report. Not before giving him his 1PM meds, of course.
1:30PM: I have just one patient now. I go into her room and find that her cooling blanket stopped being cool. And there’s a funny red button on the cooling machine that’s blinking.
1:35PM: I call central supply to see if they have another machine. They say that one’s in biomed (no kidding), and that they do have one more. They bring it to me in record time (thank you) and this 3rd machine works great the rest of the day.
2:00PM: I go to lunch.
The rest of the day was fairly uneventful; certainly nothing like the morning. Interspersed with what I described here, I had to take phone calls and patient 1 needed to be suctioned frequently, sometimes several times an hour. Patient 2 was in the unit all day, having to go on an insulin drip for his high blood sugar. I asked the nurse to pull his curtain a little so I wouldn’t have to look at him through the glass door. I catch him staring at me anyway, because he can still see out into the unit. I resisted the urge to glare at him, and tried my best to ignore him.