Wanted: thicker skin and a backbone

Over the weekend I had a pt. who came in with atrial flutter and heart rate in the 160s and on a cardizem drip from a long term care facility. Obese, 2 colostomy bags, cerebral palsy in legs, slightly MR, very needy and impatient. But, I have kids, I know how to talk calmly and sweetly enough so he doesn't get too upset. Often, all he wants is his nasal cannula adjusted or a pillow under his ankle anyway. Maybe some toast and a sip of water. So basically, when he's my patient, I'm the only one who goes in there when he calls because the aides just have no clue how to handle him. Fine, whatever.
When I got him back yesterday, found out his heart rate plummeted into the 30s that afternoon and they d/cd the cardizem drip and started him on a dobutamine drip. I recall during my ICU rotation a few of my pts running dobutamine, but I couldn't remember anything at all about the drug (honestly I didn't think we were allowed to run dobutamine on our floor). All I knew was if his heart rate went over 100 I was to shut it off. (no titrating, just turn it off) Alrighty then. So I'm doing my assessment and thinking, you know, if anything happens to that site, I'm fucked. I better try to get another peripheral site into him. I tried and I couldn't get him. Called the charge nurse, he couldn't get him. Grabbed a Dr. and told him we need a PICC line placed in him by the PICC team. Dr. put in for the PICC team consult and they will be in to place the line tomorrow am. Perfect! Now all I had to do was protect that site with some extra gauze and cross my fingers nothing happens to it.
45 minutes later he hits the call light and says, "I think my IV site is out"

FUCK.

Go in the room, sure enough the site is out. While I'm assessing the site, a priest walks in to give him communion and I'm thinking to myself "well good thing you're here, we may be needing last rites, too.."
Page the Dr. and tell him the site is out and the pt. is not getting his dobutamine. He tells me to page general surgery and have a central line placed (a little riskier than a PICC insertion but he needs the medicine and it's well known he's a tough stick). Get in touch with general surgery and the Sr. resident says, "Have you exhausted all your other resources? Called ICU units to get a peripheral site put into him? A central line should be a LAST RESORT and it sounds to me like the only reason you are asking for a central line is because you don't have the skill set necessary for this patient's needs. Keep calling other floors and if no one can get a line in the next 2 hours we will come and place the line."*slam*
I stood there stunned for about a minute and ran though about 5 scenarios in my head.. most of which ended up with my patient coding because I wasn't able to get him the help he needed in time... and I cried. I stood there right in front of the printer by the front desk and cried. Charge nurse (G) saw me and said, "WHAT DID HE SAY TO YOU? What's his number? I am calling him now.." I begged G to just help me get a the pt's dobutamine into him and we can talk about the resident's communication techniques later. I was more worried about my patient than my pride. In the midst of my crying, the priest came over and asked me if it's ok if the pt. received communion and I said yes, it's fine. (The priest looked kindly concerned for me and told me he's sorry I'm upset and he will pray for me, that was very sweet of him.) One of the nurses from our floor was able to get a line in him after all and the dobutamine was back up and running. Who knows, if not for the priest maybe things wouldn't have resolved so quickly.

Anyway, the better part of today was spent in tears, partially from exhaustion, partially from stress, partially from sheer loneliness. I hate that I internalize everything and things affect me so deeply. I can feel my healthy life perspective slipping away from me, it's getting more and more difficult for me to process all the complex scenarios (this story one simply one of MANY). All I feel left with is raw emotions and an inability to cope with them. Giving all you have to complete strangers for 12 hours a day 3 days in a row is exhausting emotionally and physically. The odd thing is, while I'm at work, for the most part, I feel invigorated. I kind of view my patients as a gift, I'm so lucky I get paid to do what I do. The downside to that is, allowing my heart into the nursing equation I think will eventually become my greatest mistake. When you give so much of yourself, you risk losing much of yourself. I hope time teaches me how to balance my emotions because if I continue on like this I'm going to suffer tremendous consequences.

Sometimes I wonder

if I'm really cut out for this.

GET THEM THE DAMN SODA

There's a new trend in hospitals across the nation. The trend is a goal of meeting and exceeding patient (and family's) expectations. (There are other trends regarding payment/reimbursement issues and hospitals not getting paid for hospital acquired infections/pressure ulcers/etc.- but I'm not discussing that today) The problem lies within the perception of what that mentality means to some nurses. There are many nurses who resent this pendulum swing into more "customer focused" type of care.. nurses who feel that they are above taking dinner trays away or getting a cup of ice water because "I didn't go to school for X amount of years so I can wait on people hand and foot." Nurses who are hell bent on being the one in charge and telling the patient to do things because they are In Charge and You Will do What I Say.

Nurses are highly trained professionals with an enormous amount of skills and who need to be able to think critically, have a solid knowledge base, be able to delegate as well as coordinate care from many different disciplines. It takes time to master all of that and it's something to be proud of for sure, but once you start thinking all those things make you "better than" having to do little things for your patient too, I have one thing to say: Get over yourself.

Your patients are scared. Maybe from lack of knowledge, maybe because they saw family members die in the hospital, maybe because of a fear of the unknown-- there's a million things that can scare them. Your patients are frustrated. 10 Drs tell them 10 different things and they don't understand 50% of what the Drs are saying because the patient is so intimidated. Their health is in jeopardy, they are facing their own mortality in a lot of cases... and some nurses will get upset because they asked for a diet soda. REALLY? Well, let me tell you what I do. I get them their damn soda and I ask their family members if I can get them something while I am in there. It's the least I can do. Look at the big picture. You are healthy, perfectly capable, and compared to the patients you are caring for, you are in a pretty good place... GET THEM THE DAMN SODA.

If you have a diabetic looking for laffy taffy, yes, you can say no and explain to them why you can't give them candy because it will affect their health badly, but if they want, you can get them sugar free yogurt, ice cream, etc. But I will tell you something else.. if I have a 96 year old man on a cardiac diet who hasn't been eating because he doesn't like the food and his son brought him in a doughnut? You bet your ass I'm going to let him have the doughnut. He's 96, for christ's sake, let the man have his damn doughnut! I believe that there's a lot to be said for life's little pleasures boosting a patient's morale and give them something worth living for.

I can go on and on with examples but my general rule of thumb is this when a patient asks for something, "Will it really hurt? If so, what's a better alternative to offer? If it will benefit them by making them more comfortable (pillow, blanket, water), just GET it- if at all possible, right away. A patient won't remember if you gave them their lopressor at 2:13pm but they will definitely remember if someone walked by their room and thought they looked cold with just a sheet on and put a blanket on them... that reminds me of one of my favorite things about working overnights. When all my patients are asleep and I am peeking into their rooms I always think to myself that they were someone's baby at some point and how lucky I am to be able to be able to watch over them like someone once did, sometimes almost 100 years ago. Nurses need to remember it's a privilege to be able to care for patients, you are not doing them a favor, you are simply doing your job- and if you are doing it well you are taking care of their body and their emotional well being. THAT is the heart of nursing.

Goodnight, sweetheart

I've had a miserable, emotional day and I am beyond exhausted so this entry will be brief.

Three peaches guy passed away last week. One of the nurses heard about it and told me since she knew I had bonded with him. (I wish I had known sooner because I would have gone to his funeral.)

I hope they played the 1950s music at his funeral that he wanted... but on the off chance they didn't....

This one is for you, Stephen. May we meet again someday, my friend.

http://www.youtube.com/watch?v=egX9N8yOgaU

Sleep

I wish I had some.

The best of the best and the worst of the worst

Well, the Big Guy is at it again.

I literally see hundreds of patients a year.. but it just so happens that the very patient who prompted me to create this blog was mine again over the weekend. :) This time it was just to have a dialysis port put in. He remembered me and that fateful day he had a rapid response. It turns out he coded a few days after that when he was in the ICU and they were able to bring him back. He also remembered what an asshole that Dr. was who didn't want to help him when he knew he was in trouble. He actually filed a complaint against her. (*clap* yay for him!) One thing about nurses is while we tend to stick together with each other and Drs. in the teamwork sense, good nurses are patient advocates above anything else. He also thanked me for listening to him and for staying with him when he was scared he was going to die. Three Peaches guy told me all about his time in Vietnam, how he enjoys fly fishing, and all about his family. He also told me he loves 50s rock and roll and at his funeral he wants that kind of music playing and how he wants his life to be celebrated when his time comes. I'm so glad he had the time to think about those things and to share his thoughts with me. It really helped the whole nursing experience come full circle for me to be able to get to know him like that. :)

And now for the worst of the worst...(if you think I'm some sort of nursey angel, prepare to be very disappointed. LOL)

Guy in his early 30s with a trach. I guess he had throat cancer or some kind of shit. I don't know and I didn't have time to read his chart thoroughly, and frankly? I don't really give a flying fuck why the trach is even there. He's on Q4 hour 2mg dilaudid, enough god damn benadryl to put down a fucking horse, and the max dose of ativan. Fucker should be high as a god damn kite and instead he walks around the unit pushing his IV pole around, looking in everyone's room, listening to everything that's going on, asking nurses questions about other patients (helloo HIPAA violation!), and basically following me around annoying the hell out of me.

So I was going around checking on all my pts. (I had 6, as usual) and I notice my frail 94 year old lady's color looked a little off and she was shivering. Temp: 99.8 Took out my little pulse ox (just bought it on amazon for 70 bucks) and it showed 75% on her finger! whaaa? noo that can't be right. Put it on her big toe.. 76%
oh fuck. Bump her up to 6L (she was on 4) Grab a hospital grade pulse ox: 75% Page respiratory. Blood pressure: 122/76 heart rate 136 (normal sinus cardiac rhythm). Grab charge nurse. He says to page her Dr. before calling a rapid response. Dr said see what respiratory says and if they think she needs a rapid response, call it. (Honestly, if the charge nurse were not there I just would've called a rapid response right then and there. Rapid responses are meant to prevent code situations and I had an awful feeling we'd be calling one.) Respiratory put a mask on her, got her up to 95%. I grab an automatic BP cuff and set it to check bp every 30 mins., and continuous pulse ox monitoring.
Then I look and see trach man is standing right outside the door. "Hey is she going to be okay?" I answer, "I'm doing my best to help her be. You doing okay?" (note how I did not say "can I help you with something?" lol) He says, "I can't take this pain anymore from this trach, I can't sleep one more night with it in, I'm going to take it out!"
My response, "Don't take it out, you won't be able to breathe. I will page the Dr." My response was calm because, frankly if he had ripped his trach out, I would have prob watched him for a few seconds, blinked, finished what I was doing, then casually looked at my phone for a few seconds before calling respiratory for the guy who was about to collapse in about 30 more seconds. Not that I believed his threats to take it out anyway.

Dr. calls back and I tell him what's going on and he says, "I have 3 traumas I can't see him right now, I know this guy and if I go in there I will be stuck in the room with him for an hour. Tell him I will have ENT see him first thing in the am to address all his concerns. So I tell trach man this and he throws a tantrum. "Why won't he see me? THAT'S IT! I'm taking my trach out!" DUDE, you have the fucking trach for 6 months and all of a sudden NOW you can't take it anymore? Seriously? Fuck you, you needy little bitch. (Kind of reminds me of a toddler acting up when the infant gets too much attention.)

Page the Dr. 2 more times and he doesn't call me back. Finally after a third time he calls me back. I tell him trach man wants to rip it out and he's very upset. Dr tells me he's still busy, I say, "Can't you send a resident?" He says, "Oh they won't be able to handle him, they are all too new." *pause* then I said, "well are there any you don't like?" It was at this point the Dr. started laughing and said "okay, I will be right up." Then trach man's wife called, so I did what any good nurse would do. I tattled. The wife called to ask me if he was in his room yet because he's not answering his cell. Then I said he was going in the room now because the Dr. is coming up to see him. Then I explained his pain and the trach, etc. and that I am just warning her he might be upset when she talks to him but that the Dr. is on his way. Wife says, "Oh he always does that. He's like a little kid. I love the man to death but he's addicted to dilaudid, and he's very attention seeking. I feel so badly for you nurses who have to take care of him. I know how he is, I will try to calm him down when I talk to him, thanks for letting me know how he's been."

I found trach man and told him to go back into his room because the Dr. is coming up to see him. Then trach man says "my tongue ith tharting to thwell" if it were anyone else I'd be freaking out but by this point I knew he was an attention whore and he was exaggerating/pretending and I had to get back to my lady. So then I told him to mention it to the Dr. since he was coming right up and that he had his limit of benadryl so the Dr. will have to write a new order for it.

Dr. orders an extra dose of dilaudid and an extra dose of benadryl and puts the guy on cardiac telem for overnight so we can make sure he doesn't overdose. 45 minutes after the aide goes in to check vitals he says, "I need a sleeping pill". Oh yeah, RIGHT he's already maxed out on dilaudid and benadryl lemme give him a sleeping pill. LOLOLOLOL I go into the room to give him his IV bag of omeprazole, he says nothing about a sleeping pill to me. THEN 10 minutes later he hits the call bell and says "Where am I?" "aide answers you are in XYZ hospital" then he says "Why am I here?" she said "your nurse will be in"
Okay Mr. Attention whore, you've just given me just the right ammo. I walked into the room, said "Are you feeling ok?" he says "oh I'm fine except...*frowny face* I can't sleep. Can I have a sleeping pill?" So I said "Oh heavens no! You sounded so confused a few minutes ago when I heard you asking where you were over the call bell, it would be irresponsible for me to give you any more meds! You're already over the limit on 2 things!"
That's right motherfucker, you and your biiiiiiiig mouth.
Doesn't he then call 10 minutes after that looking for ativan? My answer? Still NO.

130am rolls around.. 1 hour and 45 minutes to go until my shift is over.. asshole calls AGAIN.. "when can I have my dilaudid?"
I knew damn well he was due at 200am but I was running out of time, plus he had an extra dose in him from bullying the Dr. a little while before. I still hadn't charted my assessments, hadn't done any chart checks.. I had a ton of shit to do and I was going to be DAMNED if I was going to be there one fucking minute past my shift.. 12 fucking hours of this asshole was ENOUGH.

When is your dilaudid due?
0315am motherfucker. That's when it's due. So I actually told him 0315am.

I love caring for people and helping them but it royally pisses me off when people try to manipulate me and compromise the care of people who REALLY need help. My lady who had the low 02 sats made it through the night- no thanks to dipshit. It's only by the grace of God that poor lady didn't end up going to the critical care unit that night because thanks to him, I wasn't able to watch her nearly as closely as I ordinarily would have. And now on top of everything else I get to feel guilty because I'd love nothing more than to kick one of my patients right in the ass.

Sometimes being a nurse just sucks.

Quick Update! :)

Three Peaches guy LIVED! He went home with his family last Sunday. :)