Went to work this morning and was pleasently surpised as we had four nurses in the unit today, which meant I only had to take two patients. That’s something that hasn’t happenend in months…yippee. For the most part both of my patients were stable. Both Patients only spoke spanish, which made things difficult but I managed and it reinforced my need to take spanish classes…sigh more school. My first patient was a high speed motor vehicle crash who actually was on the regular med/surg floor but started develping abdominal pain, so the docs did an exploratory laparotomy and found some mesenteric tears along his belly. This patient was pretty stable, I ended up sending him back to the med/surg floor by the end of the shift after I pulled out his NG tube, Foley, and removed over 30 staples from his abdomen and taped the inscision with steri-strips. Oh by the way, did I mention this guy is a pimp. The guy 27 years old, who I might add is Fugly as sin, has like 20 girlfriends, who are also Fugly as sin, who apparently don’t know about each other. It was fun to watch this constant stream of visitors enter his room as he played off who the previous girl was. So anyway, this guy was pretty uneventful throughout the day.

My other patient however…sigh…a nice enough guy, has cancer and a lot of of it. No one is sure where his cancer started but tests show he now has cancer in his liver, adrenal glands, throughout both lungs and has now settled in his brain. This guy is most likely going to die and in a relatively short time frame and probably in an unpleasant way. So you might be saying to yourself, “well ok that’s said but people get cancer what’s so different about this patient.” What’s different is the family is lying to the patient and has forbade the hospital from telling him that he has cancer. There are a few rare execptions that this is ok, but this case does not fit any of them. So now I am in a HUGE ethical delemma. The patient is alert and oriented to person, place and time and is fully capable of comprehending the situation and able to make decisions for himself. As it was explained to me in shift report, the family doesn’t want him to become depressed! REALLY (stated with much sarcasm) are you freaking kidding me. This guy is dying, facing life altering events and decisions about quality of life and invasive, painful treatments and you don’t want to tell him he has cancer because he’ll get depressed…WHAT! But I digress, so I let my charge nurse know, who already knew and I told my manager, who again already knew and then I did something I never thought I’d have to do ever. Something they tell you about in nursing school but you kinda blow off as fluff…I called the Hospital Ethics Committee. I had to, for the sake of my patient and his right to truthful information about his condition. It will be interesting to see what happens with this over the next few days. So I kept him as comfortable as I could, and I was proud that I was able to wean his oxygen down. When I got him in the morning he was on 35 liters of high humidity oxygen at 0.40% …put simply that’s a lot of oxygen. I was able to wean him down to 8 liters on a high flow nasal cannula…huge difference.

Since my patients were pretty stable, I was able to help the other nurses in the unit. Poor Debbie had to goto MRI. Going to MRI is a pain the butt because an MRI can take hours throwing your whole day off majorly. So I watched her patients while she was off unit for which she was very thankful.

I was sitting at the nurses station trying to get some charting done when I noticed that one of Terraca’s (my charge nurse) patients SPO2 was at 88% (norm is >92%) and dropping with a good waveform on the monitor. I ran over and told Terraca what was happening. She kinda blew it off saying she was fine and that it wasn’t a true reading, but my gut and brain told me otherwise. So I left Terraca to deal with it. A few minutes passed and I saw Terraca calling for respiratory to come to the room stat, so I thought it a good thing to grab the code cart and intubation kit. Turns out this lady was really loosing her airway quickly. OH…did I mention this lady is truthfully 105 years old and a FULL CODE! What the hell is up with people today family lying to family, people over 100 years old and full codes geez. We fortunately were able to get her levels up with a CPAP machine instead of throwing a tube down into her lungs but come on people lets think about what’s going on here.

When Kim was at lunch, I was covering her patients, well one of the docs came by and said I think this patient has an abdominal infection I’ll be back in five minutes get me *insert list of medical supplies here* so I can culture what I find…thanks doc (sarcasm alert). I got what he needed and helped him open this guy’s belly and watched as the pus poured out….yum…we got our cultures and the doc left him open. No sense in closing him if its all infected.

All in all a good day in comparison to the norm.

Its been awhile since I posted so I thought I’d update ya’ll on what has been going on. Honestly, not much work mostly…ah yes work my last two days have been long…oh so long. I usually get to work around 06:45am and on a good day punch out at 07:45pm or (19:45 for you military folk) Well, for the last two days I haven’t left work until about 10:00pm, that with a 40 minute drive home makes for a long day. The critical care unit has just been nuts lately. We are constantly in a shortage of beds and a few times the hospital called a CODE 99 which means the hospital is on bypass and no longer accepting patients to the ER. So I’m not sure what has caused all the crazyniess, perhaps the moon is in a strange orbit, perhaps I put my socks on in a different order yesterday who knows. To give you an idea of what my day went like read the following:

So got to work around 6:45 as usual and made the traditional pot of bad hospital coffee, nothing unusual. Sat down to get report from the night nurses for my patient and that normally takes about an hour for a good report. Started getting report on my patient with a complicated history. Elderly gent in his mid 80’s came into the hospital a couple of weeks ago for a hip ORIF. He was lucid but with a baseline of slight dementia. In other words he was communicative but not all there when he talked. He was discharged to a rehab center and later returned for shortness of breath. He soon developed pneumonia in both lungs and become essentially unresponsive. He was constantly gasping for breath and would only breathe through his mouth. He was treated and started to come around. This patient has a PEG-Tube, a tube inserted into his belly for feedings. The docs wanted to try to feed him by mouth though so they ordered a swallow evaluation and he passed. Unfortunately, when he had the evaluation he was more lucid, when his mentation decreased he aspirated all the food he ate. It all went into his lungs and worsened the pneumonia. The night nurse and I were reviewing each of the body systems. When she got to his respiratory system she said, yeah he’s been increasingly more uncomfortable all night…had to give him like 10 milligrams of morphine to help him breathe. As we’re talking, I look over at the patient…uh oh…he is breathing 40 times a minute, blood pressure is 170/111, HR is 154 and SPO2 is 74% with a good waveform on the monitor…not good. We ran over to him and quickly assessed him. He was moving very little air. There was very little I could do for him, you see he is a FULL LET (limitation of emergency treatment) which means, No Intubation, No antiarrhythmic meds, No Vasopressive meds, and No electrocardioversion. I got the respiratory therapist STAT and had her put him on a BiPAP machine. It worked o2 level increased, respiratory rate and blood pressure, but without that machine he would most likely die. I started calling in family and they arrived in droves, but that was ok…it was time, time for me to start the talk about hospice and limiting treatments to comfort care. That’s always a hard subject to bring up. So a good chunk of the day was spent talking to family, answering questions, helping them to maintain a realistic view of the situation, setting up social workers and hospice consults, updating all the docs, etc.

Oh and the meantime, I still have two other patients all having their own emergencies at the same time. My second patient is a guy who came into the ER by ambulance because he was way drunk and was causing problems at the hotel he was staying at. Apparently, he was here on business and found his way to the bar. Several drinks later he is in a bed in my CCU. So while I’m dealing with my first patient, this guy is irate because his boss has called him and told him he’s fired for screwing up whatever business he was supposed to do and he wants to leave AMA (against medical advise), which if he did his insurance would not pay for any medical costs associated with his admission. I told him that I had no problems letting him go but I would have to have to doctor give me an order to let him go AMA. I called Dr. Swamy, while adjusting air settings on my first patient and she said don’t let him go until I see him I’ll be there in 10 minutes. I told the patient and he got more upset. I explained the insurance issue to him and told him that his blood pressure was very high, nearly 190/100. Dr. Swamy came in calmed him down a bit and actually got him to agree to letting me treat his high blood pressure and filling out all the proper discharge paperwork and we would let him go. So he was ok for the moment…

Just as I was getting that done, my first patient’s blood pressure dropped dangerously low, 70/40 at this point he is in danger of not perfusing blood to his brain. Got an emergency order for a fluid bolus and raised his pressures back…phew.

On to my third patient of the morning. A nice lady with a nice family. Nice, although they couldn’t stop even if they tried to stop asking medical advice about everything under the sun that had nothing to do with their family member’s admission…argh. So this lady had radical sinus surgery to basically enlarge the sinus cavities to help her breathing. Of course that surgery hurts right so she is on morphine right and of course morphine makes you sleepy right and morphine is a respiratory depressant…you see where this is going…you got it…she was sleeping…stopped breathing and had to emergently get her breathing back online. While I was in the room taking care of this lady, remember the alcoholic in my other room…yeah he decided to just leave and walked out without treatment. Oh my.

Ok…so keep in mind I haven’t charted anything at this point and in nursing we chart a lot. No vitals, no assessments, no documentation, the medications I gave, etc etc etc on three patients who turned into emergencies from the get go. I took a second and got a cup of the coffee I made which was now cold sat down to catch up and got a call…we need you in CT scan (the other side of the hospital) we lost IV access on a patient come help us. Crap, so I picked up the supplies I needed and ran off to the scanner to start an IV on a chemotherapy patient whose veins had sclerosed so bad that everytime someone would stick a needle in her the vein would collapse. I got her on the first try and was pretty proud of myself but it didn’t take long before that vein blew when fluid was pushed into it…sigh. We ended up having to surgically implant a PICC (peripherally inserted central catheter) line into her. I ran back to the CCU to get back to my patients.

By the time I got back I was getting an admission for the room that the alcoholic left….ARRRGHH. Of course what type of patient was I getting. An Alcoholic found by Dupage County health department unresponsive who turned combative and hit a nurse in the ER. The ER called report and because I was so busy I was taking notes on post-its and sticking them to my scrubs. I sat in the room with my new alcoholic patient and got a call from the county asking for an update…so I kinda chewed them out and said could ya give me a minute. This wasn’t the first time the county sent patients like this to us…we’ve become a dumping ground for them..and these types of patients don’t’ truly meet the admission criteria for our unit, our administrators just don’t enforce the rules. Normally, I don’t care just this day it was all a bit too much.

As I sat in the room trying to get baseline information on my admission, the doctors for my sinus surgery patient called and said well she is fine she can be discharged….WHAT! Yep, the docs came by while I was in CT and said well the breathing issue was an isolated incident, we changed the morphine to an oral vicodin dose so she’ll be fine so go ahead and get her discharge paperwork and education packet ready. Naturally, the family that had been in the room was gone and I had to track them down so this lady would have a ride.

Oh still haven’t charted.

Now I let the unit charge nurses know my updates and naturally they have another admission for the room with the lady I haven’t even discharged yet…my oh my what a day.

So as I’m trying to catch up another nurse runs up to me for help her dopamine drip infiltrated. Dopamine is a powerful drug that is caustic to subcutaneous parts of the body and can quickly progress to something like this:

So I helped her with an emergency Regitine administration to prevent the drug from running amok in the patient’s arm.

Whilst that was going on I was trying to console family who were quickly coming to the realization that their loved one ( my first patient ) was dying.

Of course simulataneously, I was getting requests (have I mentioned I’m pretty damn good at IV starts) for IV starts on patient who just have terrible veins. I think it was the moon phase thing again…sheesh.

With all said and done, I didn’t get a lunch and it took me an extra three hours to chart all the events of the day.

Tomarrow is the Fourth of July….hummm….I wonder what that will bring