30 October 2009
tolerance level
You wonder what a patient's home meds (prescribed or otherwise) consist of when freshly post op, they are flailing around in the bed, on the ventilator, in restraints, a look of murder in their eyes, and a max of diprivan isn't touching them. Think that bottle was just bad or perhaps this person takes an ungodly amount of drugs? I vote for the drugs. Thankfully, a little vitamin A on top of it all did the trick :)
24 August 2009
sunshine, butterflies, and rainbows.... really?
So report went something like this: This patient coded on the way in, but we revived them and now they are coming to you, on the vent, here are the settings... here are the labs... here is the monitor pattern... here are the meds they got down here.... here are the ivf's running... hx and allergies, family is with them, will bring them up in a few minutes. General report.. nothing special or out of the ordinary. Lots of sunshine, butterflies, and rainbows.
None of it prepared me for the patient they wheeled around the corner to come into the unit. They forgot to mention... the patient was... not even cyanotic, but more of a raspberry color. They didn't mention that... the patient was... having uncontrollable decerebrate muscle spasms. They forgot to mention that... the patient coded at home, over 40 min. away from the hospital. Oh and they forgot to mention that they actually coded the patient downstairs, called the code, and suddenly they got a rhythm back on the monitor and so they reconnected all life support because the family wanted everything done.
I yelled at my colleague when they wheeled the patient around the corner... "I didn't get report on that!" We laugh about that now, but it certainly was not funny at the time. The attending md was actually on the unit at the time, and this patient was one of his for a very long time, and he knew them very well. I have to say that he was speechless, and this certain md is never speechless. He just stood there and stared while we went to work on this neurologically devasted patient who was only kept alive by the ventilator.
Lesson learned. Beware the sunshine, butterflies, and rainbows... there is usually a storm brewing on the other side.
None of it prepared me for the patient they wheeled around the corner to come into the unit. They forgot to mention... the patient was... not even cyanotic, but more of a raspberry color. They didn't mention that... the patient was... having uncontrollable decerebrate muscle spasms. They forgot to mention that... the patient coded at home, over 40 min. away from the hospital. Oh and they forgot to mention that they actually coded the patient downstairs, called the code, and suddenly they got a rhythm back on the monitor and so they reconnected all life support because the family wanted everything done.
I yelled at my colleague when they wheeled the patient around the corner... "I didn't get report on that!" We laugh about that now, but it certainly was not funny at the time. The attending md was actually on the unit at the time, and this patient was one of his for a very long time, and he knew them very well. I have to say that he was speechless, and this certain md is never speechless. He just stood there and stared while we went to work on this neurologically devasted patient who was only kept alive by the ventilator.
Lesson learned. Beware the sunshine, butterflies, and rainbows... there is usually a storm brewing on the other side.
23 August 2009
why?
just curious. why is there always a war between the er nurses and the inpatient nurses. i say inpatient because it really isn't limited to just the med-surg floors, but all the units. and the same goes for docs as well. attending docs always seem to have some sort of irritation related to the er/ed, whether it is with the docs or the nurses down there. i don't get it, personally.
seriously.
has it been that much over a year since i have posted one single thing to this blog? guess i have just been that busy. sigh.
23 March 2008
Just how sick are you?
We have had our fair share of super sick patients recently. And this is not necessarily a good thing. In all of the cases, each patient waited too long to seek medical attention.
Patient 1; late 20s: presents to the ER with difficulty breathing, fever, chills. Pt is sent to ICU with RR in the 40s and with an insulin drip. Pt is alert, able to talk, but is very uncomfortable. Throughout the night, I keep a close eye on this patient because I had a really bad feeling in my gut. Sats say upper 90s but I tell the other nurse with me that I just don't believe it. White count is over 40. While working through the admission, I ask the other nurse to please see if she can get me a couple more IV sites. BP stable, but HR increasingly tachycardic, in the 120s. As the night progresses, RR goes up to the 50s, HR goes up to sustained 180s. Sats and BP bottom out in a flash. Pt is in respiratory arrest, and is subsequently intubated. This happens at shift change. Later that same evening, the patient goes asystole and is coded, but is brought back. And what is brought back is not the same person that I admitted. This newer version of the patient has gross neurological deficits. This patient, who was able to talk at admission, is now pretty much a vegetable. We were sure that they wouldn't make it. Now, a month and a half later, the patient remains in the hospital with a peg tube and will need long term care for the rest of their life.
Culprit? Strep pneumonia.
Patient waited 2 weeks before seeking medical care.
Did you realize that 30% of pneumococcal patients become septic and then 30% of those die?
Patient 2: Patient in their 80s, presents to the ER with fatigue, weakness, and cough for 1 wk. Pt is transferred to the ICU due to hypotension and tachycardia, but was admitted to the hospital with pneumonia. Upon arrival to my shift, I listen to lung sounds and all I hear is water. Everywhere. Pt is alert, but a little nauseous. Nailbeds are dusky. O2 @ 6L per nc. White count 1.0. History of CA, but not currently. + Blood cultures. No urine output. As the night progresses, pt is unable to sleep,but is alert and talking. I teach the patient how to use the yankauer to suction the secretions out so that they would not have to use tissues, which in turn, dry out the mouth. It almost seems that the patient is getting better? Which I know is not necessarily a good sign. The next night, the patient expires. I heard it on the radio.
Culprit? Strep pneumonia.
I recently read that when white counts are low, it is not necessarily speculative of cancer, but in fact can be due to an infectious process so widespread that the body isn't able to produce enough white cells to counter those being used to fight the infection.
Patient 3: Late 30s, presents to the ER with abdominal pain for 3 days. Yeah, a regular presentation, but after testing, the patient is rushed to surgery as this patient has a perforated ulcer. Comes to the ICU post op and on the vent. I didn't personally have this patient, but I assisted with the care for 3 nights of hell. BP won't stay up, has to be on dopamine and then an epi drip. Pt is in renal failure. Continues to be on 100% FiO2 on the vent because this patient cannot tolerate any type of weaning before the sats bottom out. Pt is now in multi-system organ failure and expires 2 nights after my last shift that week. Died of pulmonary edema.
Culprit? Septic from a perforated ulcer.
Sad case, really.
Patient 4: mid 70s, presents to the ER with abdominal pain for at least a week. Admitted to the floor and to see the GI doctor, who subsequently schedules surgery for the next morning. Arrives to the ICU on the vent, but doing well. Surgeon tells the family that this patient waited too long to seek care, that it was possible that this patient would not survive this. Pt has so much ischemic small bowel, that there is nothing left at this time to take out and put together. 2 days later, the surgeon goes back in for another ex lap, and finds pink bowel. Only has to remove 6 feet and is able to reconnect the remaining so that this patient does not even need an ileostomy. A week later, patient is able to move the floor, completely stable, and completely aware of how close they came to dying. This was truly some type of miracle. This patient attributed it to the praying done at church.
No culprit this time. This patient was lucky.
Patient 1; late 20s: presents to the ER with difficulty breathing, fever, chills. Pt is sent to ICU with RR in the 40s and with an insulin drip. Pt is alert, able to talk, but is very uncomfortable. Throughout the night, I keep a close eye on this patient because I had a really bad feeling in my gut. Sats say upper 90s but I tell the other nurse with me that I just don't believe it. White count is over 40. While working through the admission, I ask the other nurse to please see if she can get me a couple more IV sites. BP stable, but HR increasingly tachycardic, in the 120s. As the night progresses, RR goes up to the 50s, HR goes up to sustained 180s. Sats and BP bottom out in a flash. Pt is in respiratory arrest, and is subsequently intubated. This happens at shift change. Later that same evening, the patient goes asystole and is coded, but is brought back. And what is brought back is not the same person that I admitted. This newer version of the patient has gross neurological deficits. This patient, who was able to talk at admission, is now pretty much a vegetable. We were sure that they wouldn't make it. Now, a month and a half later, the patient remains in the hospital with a peg tube and will need long term care for the rest of their life.
Culprit? Strep pneumonia.
Patient waited 2 weeks before seeking medical care.
Did you realize that 30% of pneumococcal patients become septic and then 30% of those die?
Patient 2: Patient in their 80s, presents to the ER with fatigue, weakness, and cough for 1 wk. Pt is transferred to the ICU due to hypotension and tachycardia, but was admitted to the hospital with pneumonia. Upon arrival to my shift, I listen to lung sounds and all I hear is water. Everywhere. Pt is alert, but a little nauseous. Nailbeds are dusky. O2 @ 6L per nc. White count 1.0. History of CA, but not currently. + Blood cultures. No urine output. As the night progresses, pt is unable to sleep,but is alert and talking. I teach the patient how to use the yankauer to suction the secretions out so that they would not have to use tissues, which in turn, dry out the mouth. It almost seems that the patient is getting better? Which I know is not necessarily a good sign. The next night, the patient expires. I heard it on the radio.
Culprit? Strep pneumonia.
I recently read that when white counts are low, it is not necessarily speculative of cancer, but in fact can be due to an infectious process so widespread that the body isn't able to produce enough white cells to counter those being used to fight the infection.
Patient 3: Late 30s, presents to the ER with abdominal pain for 3 days. Yeah, a regular presentation, but after testing, the patient is rushed to surgery as this patient has a perforated ulcer. Comes to the ICU post op and on the vent. I didn't personally have this patient, but I assisted with the care for 3 nights of hell. BP won't stay up, has to be on dopamine and then an epi drip. Pt is in renal failure. Continues to be on 100% FiO2 on the vent because this patient cannot tolerate any type of weaning before the sats bottom out. Pt is now in multi-system organ failure and expires 2 nights after my last shift that week. Died of pulmonary edema.
Culprit? Septic from a perforated ulcer.
Sad case, really.
Patient 4: mid 70s, presents to the ER with abdominal pain for at least a week. Admitted to the floor and to see the GI doctor, who subsequently schedules surgery for the next morning. Arrives to the ICU on the vent, but doing well. Surgeon tells the family that this patient waited too long to seek care, that it was possible that this patient would not survive this. Pt has so much ischemic small bowel, that there is nothing left at this time to take out and put together. 2 days later, the surgeon goes back in for another ex lap, and finds pink bowel. Only has to remove 6 feet and is able to reconnect the remaining so that this patient does not even need an ileostomy. A week later, patient is able to move the floor, completely stable, and completely aware of how close they came to dying. This was truly some type of miracle. This patient attributed it to the praying done at church.
No culprit this time. This patient was lucky.
Needed a break.
Took a break from the internet for about the last two months as I have switched over to working nightshift. Just didn't have the motivation to post anything, or do much of anything on the computer at all except read emails. So anyways, am back now :)
26 January 2008
FAST
There was a patient who fell at home. Admitted to telemetry for syncope, which is a usual type of admission. Up and about, talking to family, walking to the bathroom, usual activities. Around shift change out on the floor, the nurses call the rapid response team. Pt has had a significant neuro status change. The pt is reassessed and md called. Pt is transferred immediately to the ICU.
Upon arrival, we all go in the room to assist with the admission. Primary nurse is assessing while the other nurse and I get the patient hooked up, vs, etc. At this time, the patient is barely responsive, has significant left sided weakness, and is having difficulty with secretions. Prominent facial droop to the left side. BP is 200s/100s. HR tachycardic with bursts of svt and vtach. Full code. Nurse calls the md and tells him to get in here now. You see the pt was a prominent VIP around town and the admitting md knows the patient personally.
As soon as the doc arrives, we assist him in performing an elective intubation. Amiodarone is given which stops the vtach episodes. The patient is sent downstairs for a stat CT. Doc is on the phone with trauma center attempting to find placement so we could get this patient shipped out. Until the films are done.
There would be no shipping this patient anywhere. The patient had a fatal hemorrhage that displaced almost the entire right side of the brain, and the only thing keeping them alive at this time was the ventilator and medications. Posturing is evident. Seizing is evident. The spouse wants to wait for the all of the children to come in to say goodbye. And so we oblige their wishes. The next day, the patient finally passes 15 minutes after being taken off of life support.
Not all stroke outcomes are such as this. A couple of important details that aren't in the story: Admitting CT showed absolutely no sign of hemorrhage. Secondly, the patient was on Coumadin, which probably contributed to the massive size of the bleed.
It is important for us as medical personel to remember the quick assessment for a stroke: FAST.
F: Face
A: Arms
S: Speech
T: Time.
Never underestimate the significance of your neuro checks.
Upon arrival, we all go in the room to assist with the admission. Primary nurse is assessing while the other nurse and I get the patient hooked up, vs, etc. At this time, the patient is barely responsive, has significant left sided weakness, and is having difficulty with secretions. Prominent facial droop to the left side. BP is 200s/100s. HR tachycardic with bursts of svt and vtach. Full code. Nurse calls the md and tells him to get in here now. You see the pt was a prominent VIP around town and the admitting md knows the patient personally.
As soon as the doc arrives, we assist him in performing an elective intubation. Amiodarone is given which stops the vtach episodes. The patient is sent downstairs for a stat CT. Doc is on the phone with trauma center attempting to find placement so we could get this patient shipped out. Until the films are done.
There would be no shipping this patient anywhere. The patient had a fatal hemorrhage that displaced almost the entire right side of the brain, and the only thing keeping them alive at this time was the ventilator and medications. Posturing is evident. Seizing is evident. The spouse wants to wait for the all of the children to come in to say goodbye. And so we oblige their wishes. The next day, the patient finally passes 15 minutes after being taken off of life support.
Not all stroke outcomes are such as this. A couple of important details that aren't in the story: Admitting CT showed absolutely no sign of hemorrhage. Secondly, the patient was on Coumadin, which probably contributed to the massive size of the bleed.
It is important for us as medical personel to remember the quick assessment for a stroke: FAST.
F: Face
A: Arms
S: Speech
T: Time.
Never underestimate the significance of your neuro checks.
22 January 2008
short update
Just wanted to add in real quick that my nights preceptor is completely and totally different. Makes for a much better learning experience. Now I know I haven't posted much lately, just haven't been terribly inspired. Am working on it though.
16 January 2008
Preceptors
What is it that makes a person a good preceptor? What are things that they do that makes them, well, not so good?
Does the preceptor need to adapt to the orientee, or should the orientee adapt to the preceptor?
I would like some input from others, your experiences, so that I can sort through what went wrong with my day shift preceptor.
So how did your preceptor teach and treat you? What worked the best, what didn't work at all?
Thanks in advance. :)
Does the preceptor need to adapt to the orientee, or should the orientee adapt to the preceptor?
I would like some input from others, your experiences, so that I can sort through what went wrong with my day shift preceptor.
So how did your preceptor teach and treat you? What worked the best, what didn't work at all?
Thanks in advance. :)
15 January 2008
Pity Party for One
The party is for me. Because I am pitiful. True. At least I feel pitiful.
The first six weeks of orientation have ended. Not necessarily on a good note. I would go into all of the sordid details, but it would be a book. Really. I just want to say that every person has their own breaking point. Mine was about 2 weeks ago.
Now it's time to reflect, rebuild, and grow. And hopefully my preceptor on night shift doesn't lose focus on teaching me about critical care. Sigh.
I think I will go watch some tv, and indulge in some escapism for awhile. And maybe eat the rest of that pint of Ben & Jerry's sitting up in my freezer, calling my name.
The first six weeks of orientation have ended. Not necessarily on a good note. I would go into all of the sordid details, but it would be a book. Really. I just want to say that every person has their own breaking point. Mine was about 2 weeks ago.
Now it's time to reflect, rebuild, and grow. And hopefully my preceptor on night shift doesn't lose focus on teaching me about critical care. Sigh.
I think I will go watch some tv, and indulge in some escapism for awhile. And maybe eat the rest of that pint of Ben & Jerry's sitting up in my freezer, calling my name.
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