Torture?

There are some days that I feel like I'm working in a torture chamber rather than a hospital. Elderly confused patients who clearly do not want the interventions that are being forced upon them: Are we doing more harm then good?

Restraint Comic

Yeah, this pretty much says it all.

"Never trust doctors"

Me: Doctor, my patients heart rate has been consistently greater than 110.

Doctor: Ok, lets try metoprolol 12.5mg IV every 6 hours. We give that, right?


Me: Ummm, yeah? Metoprolol 12.5mg IV every 6 hours, correct?


Doctor: Yes.


Me: Ok, thank you.


*hangs up phone and shows my preceptor the order as I had jotted it down*


Preceptor: OH MY GOD! You can't give this! You'll kill someone!!! Are you sure this is what the doctor ordered??


Me: Yes, I'm sure. I read the order back to him. He asked me if we could give this. I didn't really know without looking it up.


Preceptor: We have to get this changed. Call him back and tell him we can give 5mg IV. 12.5mg is a PO dose.


Me: *feeling very stupid and unsure of myself*   Umm, Can you call him please?


*medical director peeks head around from the other side of  computer monitor where he was sitting about 4 feet away from me*


Medical Director: *in a kind voice*   This is your lesson for the day. Never trust doctors. We depend on you to keep us from killing patients.





I think it's time to be scared now.

IV Starts

I can change the trachs of 3 month old babies. When I say "change the trach", most people assume that I mean changing the inner cannula. If you are not a pediatric nurse, you may not realize that pediatric trachs don't have an inner cannula. The entire trach is removed and a replaced with a new one approximately once per week. This is scary for pretty much every nurse until you gain confidence in your ability to manage emergencies (such as being unable to insert the new trach). I've had lots of experience. Doing this routine procedure does not bother me in the least.

I can insert foley's and straight cath patients of all ages and sizes. Again, doesn't bother me in the least.

I can give injections. No problem.

I can insert nasogastric tubes. No biggy.

I can pack stage IV decub ulcers down to the bone. I enjoy wound care.

So why in the hell can't I start IVs?!? I get nervous as all get out. I psych myself out before I even start. My hands shake scaring my patient half to death. I know I certainly wouldn't want to see me coming at me with a needle in my state! Why does this seemingly simple procedure get me so nervous? I just don't get it. I've done a lot of things much more difficult than this.

I got to spend a day with the IV nurse doing nothing but IV starts all day. I thought this would cure me. Big Fat NO. Out of about 7 attempts, I managed to get 3 in all by myself. The others I either missed entirely, blew the vein, or had to step aside to allow the IV nurse finish what I started because for some reason that I can't figure out, I couldn't advance the catheter!

It's not the actual IV stick that gets me so worked up. It's the thought of failure. Of missing that IV, of having to tell the patient I need to stick them again, then, when I miss for the second time, of telling the patient that I will get another nurse to try because I'm a big fat failure that has tortured you enough for one day. I get wound up just attempting to look for a suitable vein, especially when I can't seem to find any!

I know I'm psyching myself out. What I need to figure out is how to get outside of my own head.

Dr. Dickhead

Background info:

morbidly obese patient admitted with DKA secondary to major cellulitis infection, consult with pulmonologist

Dr. Dickhead: So, I'm here to see you regarding your sleep apnea. Your sleep apnea would improve if you lost weight.

My Patient: Yes, I know. I've had a rapid weight gain of about 150lbs in the last year or so.

Dr. Dickhead:  I see that you have been noncompliant with your diabetes, otherwise you wouldn't be here. (patient's Hemoglobin A1C was on the low normal side)

My Patient: I check my blood sugar a minimum of four times a day. It wasn't until the past week that I couldn't get the levels under control.

Dr. Dickhead: What do you do for a living?

My Patient: Well, I have a Ph.D. and used to be a counselor. Now, I'm a pastor.

Dr. Dickhead: *saracastic tone of voice*   Did you used to counsel people on weight loss?

My Patient: Why yes I did.

Me: *picking jaw up off the floor while shooting the "doctor" daggers with my eyeballs*

You know you're tired when...

leaving work after a 12 hour shift, you attempt to use your ID badge to "swipe" into your car.

Cardioversion

It was a hectic day, but I'm loving learning all I can. Today I got to assist with my first cardioversion. The cardiologist in our unit loves to teach and he has spent many 1/2 hour long teaching sessions with me when the opportunity arises.

Today he asked me to come to the room next door when I was finished with my patient. I walked in and they were getting ready to perform a cardioversion. The patient was in A Flutter. The Life Pak was already hooked up and conscious sedation administered. The cardiologist explained everything to me about the process. Even though the nurse educator had already extensively gone over this with me, it's good to have a reminder when you're nervous.

I operated the Life Pak under the direction of the cardiologist. The patient went into A Fib after I had delivered the first shock. I admit, I jumped a little when the patients body jerked slightly with the shock. When I delivered the second shock, the patient sat straight up and said "Ow" before falling back onto the bed. I jumped again. But he was in sinus brady and all was well.

The cardiologist took the next 15 minutes to explain everything to me, review the meds used for conscious sedation and how the patient won't remember any of it. He even made a point to wake the patient up and ask him if he had felt any it, to which the patient replied "no".

It was a good first experience. The people on my unit are very supportive and understanding with new nurses and are quick to include us when there are good learning experiences. I look forward to the day when I can be that experienced nurse helping the new nurse.

My first code

All I can say is, "What the hell have I gotten myself into?".  It was a Sunday and I worked two back to back 12 hour shifts. I had the same 2 patients (who were very stable) as I had on Saturday and thought it was going to be an easy day.

Lesson learned: NEVER even think, "Wow, I'm starting to get this down, I think today is going to go pretty easy". Never.

One of my stable patients was taking a turn for the worse and I watched him go downhill all day while we did various interventions. Approximately one hour before the end of my shift I went in to check on him and recorded his vital signs which were actually starting to improve a bit.

1800:  My patient: Hey girlie! How ya doing?
          Me: Great thank you! How 'bout you?
          My patient: Doin' fine!

1813: My preceptor screaming from the direction of my patients room: I need help in here right now!!

Everyone just stopped to stare for what seemed like way too long before they realized something was wrong and sprung into action. I am pleased with myself that I did react so quickly. I think I plowed down the respiratory therapist as I made a mad dash towards the room. Really, it is all a blur but oddly at the same time it felt like everything was moving in slow motion. I was scared out of my mind, but it's a good sign that I ran towards the room rather than away from it, right?

Anyway, my patient had pulled off his high flow oxygen and quit breathing. He was gray and unresponsive but his heart was still beating. I was amazed at the number of people in the room, all working as fast as possible to get him intubated. It was exactly 12 minutes from the time my preceptor yelled out for help until he was successfully intubated.

I helped where I could, but mostly stood back and observed as instructed to do so by my preceptor. I wonder if I can do this. I KNOW I can, I will learn, but wow, after it was all said and done, I really felt like I didn't know my head from my ass. Is this what it's like to be a new critical care nurse?

It's starting to come together

The last two days have gone very well. I'm starting to become more organized and better at getting my assessments, charting, and care provided for one stable patient. My goal for next week is to accomplish this for two stable patients. I've accurately interpreted all my heart rhythms thus far, though I haven't had any real difficult ones. My preceptor is telling everyone what a good job I'm doing so that makes me feel good. The best part....I am absolutely LOVING my job. I love talking to my patients, getting to know them, getting to help them, getting to teach them. Seriously, there is nothing I dislike (so far).

I loved pediatrics. But I do believe, I'm loving this even more. I'm probably an "all around" nurse. Meaning, I love working many different specialties. I love peds, adults, elderly. Age doesn't matter. I'm loving critical care. I loved med-surg when I did that as an agency nurse. I loved home care. I loved long term care. There were always aspects that I didn't particularly enjoy (such as the under staffing in LTC or politics in homecare), but really, I love all areas of nursing. I truly hope that one day I can add ER nurse and even flight nurse to my list.

One thing I have noticed, critical care nurses are VERY opinionated about a patients DNR status. They tend to get worked up and upset when somebody whom they believe should be a DNR is not. Either the doctor "convinced" the patient to not be, or the family can't accept that death is part of life, or whatever reason is applicable at the time. I have my own beliefs, but I don't have an opinion on what others choose....yet. I'm sure after I've cracked the ribs from doing compressions on a 90 year old frail lady or gentleman a few times, only to prolong pain and suffering for another month or two, I may feel a little differently.

As a new person on the unit, I feel like an outsider looking in sometimes. I see things that I aspire to do and be. I see things that I know I don't want to do or become. But I also realize that I don't really "know" yet, as I've got SO much to learn. All I know is that I hope that I can keep my passion for nursing burning well into my career.

Delirium tremens

Last week I helped care for a Vietnam vet who had come to our unit with an extremely high blood alcohol level. High enough that most people would be in a coma, or even dead with a level as high as his. He was a chronic heavy drinker, consuming approximately 4+ cases of beer per week. He has end stage liver disease, and because of the DT's he was sure to face and a GI bleed, he was admitted to our unit for close monitoring.

We talked with him about all of his options. He knows he is going to die. He openly told this to us. His wife divorced him, his daughter doesn't speak to him, and he is sure that his liver won't last the amount of time required for him to be "dry" before he could even become eligible for a transplant. He recognizes that he could have done things better, but his feelings on the matter? "If I'm going to die anyway, I might as well keep doing the things I enjoy". At this point, I'm not sure I could blame him for not wanting to quit. Despite the hell he was going through, his cravings for a cigarette and a beer, his hunger from being NPO, and the pain he was in, he had to have been one of the nicest patients I had cared for. Always polite, respectful, and appreciative. I'm not sure I could have been as nice as him if I was feeling only half as crappy.

Today he was readmitted back to the hospital, though not in my unit. His blood alcohol on admission was only around 0.08 or so. I was amazed, and I paid a visit to him during my lunch break. He looked awesome! I couldn't believe it. He just looked healthier and in better spirits. He informed me that he had just had approximately 4 liters of fluid removed from his abdomen. He told me that he was really trying, and is currently down to about 4-5 beers a day. He looked very happy to see me, and told me how much he appreciated me coming to visit him. I think it's important to show people you DO care, and it can be doubly important for someone who doesn't have that family support system and believe that nobody cares about them.

He will have to continue to have fluid drained from his abdomen every 4-6 weeks. I hope he continues to try to improve his health. I wish him all the luck.