One heck of a week...

It's been an interesting week, to put it mildly. Before I became interested in the wonderful field of nursing, I had absolutely no idea what these poor souls did. When visiting friends or family in the hospital, I never suspected how much crap nurses dealt with on a daily basis.

Sometimes it's the patient that can drive you damn near batty, but more often than not, it's the people you have to deal everyday. Patients in my unit (PACU) are often sedated with pain medications, sedatives, etc., plus they are transferred to another department within 30 minutes to an hour (if they're stable of course.) Too bad that we can't give our co-workers something to pipe them down too!

Case in point...
CRNA brings a patient in to recovery S/P I&D of infected elbow. Patient has oral airway on arrival to PACU. Respirations of about 6 per minute, SpO2 of 79-93% with jaw thrust maneuver and 10 LPM via face tent. Unresponsive, was reversed at the end of the case. I get report, (while holding his jaw, naturally), and what kind of pain med did he get 30 minutes earlier while in the OR under anesthesia? Why 20 milligrams of morphine....all at once. CRNA *attempts* to leave. Oh no, I don't think so. Insert a nasal airway, opt for a larger OAW, attempt to stimulate. SpO2 is up to 82-92% (still holding that jaw.) CRNA tries to leave. I don't think so.

After about 10 minutes of this, I finally get the guy to give him some Narcan. So he gives 40 micrograms. Mr. Elbow's respirations pick up to around 12, still has OAW and NAW intact. SpO2 92-96% on 10 LPM via face tent. Okay, you can leave now.

Mr. Elbow is arousable now. OAW and NAW discontinued. Respirations deep and even, decent O2 sats, wean his O2 to 2 LPM via nasal cannula. He continues to be somnolent and has one of the worst cases of obstructive sleep apnea I've ever seen, sats are up and down. So, I end up giving him 40 mcg of Narcan times 2. He finally wakes up, (while maintaining more than adequate analgesia), and I can get him off to the floor. And yes, I give a detailed report to the receiving nurse about the entire incident, and caution against the possibility of re-narcotizing.

Two hours later, I get a phone call from the charge nurse where Mr. Elbow has been sent to spend a lovely overnight vacation in paradise. Same problem, though not as severe as it was in PACU. Even though I am not obligated to follow up as this is no longer my patient according to hospital policy, I go upstairs and do it anyway (after all, it is my license.) When asked about his apnea, wife tells me that he sleeps like that all the time, never even thought about a sleep study. The charge nurse has already contacted the surgeon and was unsuccessful at getting an order for Narcan.

My only option is to contact the anesthesiologist on call. Great. I'm sure he'll want to hear this in the middle of the night. Luckily, he's a pretty good old boy. Tell him the story and he asks me if I gave pain meds in PACU (why hell no.) Gives me an order for Narcan IM, continuous pulse oximetry (I've already got it on Mr. Elbow), O2 (got that on too), no IV pain meds (he had dilaudid ordered) and respiratory rate checks every hour. Then he wants an incident report on the CRNA due to the morphine given in OR. (He'll love me for that, I can assure you.)

Anyway, the floor nurses are happy now, they've got the orders they needed. My nursing license is happy now because it's safe for the moment. The anesthesiologist is happy, his patient had a good outcome (even thanked me for going up there to check it out...that's unusual in itself.) Elbow's wife tells me this morning that Elbow's brother informed them today that their father had OSA so bad that he had a UPPP (trimming of soft tissue in the throat.) Imagine that. Elbow was discharge with an order for a sleep study.

There are some great CRNA's out there that are a pleasure to work with, don't get me wrong. But every bowl of cherries has it's pits. Another one brought me a 17 year old with an O2 sat of 17%, get the bag out. (You could see her neon blue lips when she rolled through the door from the OR.) That's a whole 'nother story.

No morphine for you....

This one's dedicated to all the drug-seekers....

Female patient in mid-20s undergoes a simple procedure in the OR, extubated shortly after arriving in the PACU. First words out of patient's mouth were complaints of pain. Not an unusual complaint, after all, she just came out of the OR. However, 99.9% of patients that undergo this particular procedure never complain of any pain whatsoever (no incision involved.) This chick is the other 0.1%. Obnoxious, agitated, demanding and just plain old nasty.

Review of her chart reveals an allergy to Morphine and "Narcotics" without any further specifics. She goes on to state that she is not allergic to morphine, she just has "some itching." Uh-huh. This is going to be good. Patient states that she is hurting and wants to "go back to sleep." I ask her if she has any reaction to Demerol to see what she says. She doesn't even ask what Demerol is and goes on to state that she has no reaction but it doesn't help her "at all." Um- hum...

This particular PACU has standing orders that permit the RN to decide which pain med and how much to give based on patient need and nursing judgement. (I also work at another PACU in which the specific order has to be written by anesthesia before giving any med. That's another story.) So, she's allergic to morphine and "narcotics" therefore, I'm not giving her any. After telling her, "I'll be right back, I'm going to get your pain medicine," I walk to the Pyxis to pull it. Of course, she's watching my every move. I promptly return to the bedside with a vial of Toradol. (Non-narcotic pain med for those that have not heard of it.) She's looking extremely pleased as I draw it up and proceed to push. At this point, another nurse has returned to take this patient because I have another one in the next bed.

She asks, "Was that morphine?"
Me: "No."
Patient: "What was it?"
Me: "Toradol."
Patient: (Screaming) "TORADOL!!!!!!"
Me: "Yep."
Patient: (Still screaming) "I thought you were giving me morphine!!!!! Toradol is useless!!!!"
Me: "I'm not giving you anything that you are allergic to."
Patient: "But I'm not allergic! I just itch!"
Me: "That's an allergy. We can't give anything that you're allergic to."

Proceed to give a full report to her new nurse victim. Patient continues to complain of pain, decides to tell nurse that she will try the Demerol, "even though it doesn't work" for her. Nurse gives 25 of Demerol. Patient has a huge histamine release, redness, itching, whelps...

So, she gets Benadryl IV. States she just wants to go to sleep. Nurse finally convinces her to settle down and close her eyes. Within a few minutes, we have peace and quiet.... finally.

Thought for the day:
It may be that your sole purpose in life is to serve as a warning for others.

Thought for the day....

Some days you are the bug, some days you are the windshield.

On a happier note....

Before you all come to the conclusion that the main focus of my blog is to simply complain about the goings on in the wonderful world of medicine and the like, I'm going to try to redeem myself here. I have had the pleasure to work with some of the most professional, courteous doctors and nurses imaginable.

Here's my "gratitude" list for docs (in no particular order):
1. Thank you for your patience when explaining or showing me how to carry out your orders when you requested that I do something I've never done before.

2. Thank you for not being short (or worse) with me on the phone in the middle of the night when I had a concern with your patient or needed to report an abnormal lab value.

3. Thank you for getting up out of your chair to assist me with a combative patient when you could have sat there and waited on someone else to do it.

4. Thank you for picking up the phone and ordering that CXR when I was the only one in the unit and the patient was critical.

5. Thank you for calling to check on your critical patient and giving me the opportunity to voice any concerns rather than telling me to call the "on-call" doc if I have any problems.

6. Thank you for taking the time to learn my name and then addressing me by it whenever we meet.

7. Thank you for realizing and acknowleging that I am doing my best for you and your patient. I can't control how quickly the lab gets your results back to me for those stat labs or what have you, but I appreciate the fact that you are not blaming me for their shortcomings.

8. Thank you for asking my humble opinion about your patient and his condition. It's nice to know that I'm thought of as a colleague with a brain, not simply as your hand-maiden.

9. Thank you for writing legibly so that I don't have to call a staff meeting to decipher your orders.

10. Thank you for returning my page promptly. If it wasn't important, I wouldn't have called you.

All in all, we are a team, you and I. Like a well-oiled machine, we work best when all the cogs are lubricated and fit into one another as a hand in glove. I need you and, like it or not, you need me. There is nothing more rewarding than working with a doctor that you have respect for and that respects you. It makes all the difference.

Okay, enough of that mushy crap...

Here's my thought for today:
"It's always darkest before dawn. So if you're going to steal the neighbor's newspaper, that's the time to do it."

Stupidity....

Had a great time playing tennis today with Son. What a wonderful way to "let go" of the agression that has been eating away at your insides. I'm most aggressive when bouncing the ball off the wall. WHACK!!!! WHACK!!! Ahhhhh, nothing feels quite as good as hitting the ball so hard that your teeth feel the impact. What does this have to do with stupidity?? First of all, it has to do with my own stupidity for renting my MH to my in-law (see previous post.) More importantly, it has to do with the stupidity of some of my co-workers. This includes nurses, CNA's, doctors, lab technicians, radiology techs.... and the list goes on.

First story to come to mind is one that happened a few months ago. Patient had a thyroplasty due to a paralyzed vocal cord. Of course, there are airway concerns due to the procedure, but this was even more so due to the gentleman's size. I'm talking nearly 500 pounds of barely breathing flesh here people. O2 sats are sucking (anywhere from 75% to 96% on 10 LPM humidified O2 via face tent) but the guy is alert and oriented. So far so good... Ask our aide to get me a trach tray, better safe than sorry is my motto. After questioning me about it, I finally get my point across and she gets the tray. So, I keep the guy in PACU to watch him for about 45 minutes or so. O2 sats improving (anywhere from 86-96% now.) He meets criteria for discharge to day surgery so here we go.

I push the (heavy) stretcher back to his day surgery room, hook the O2 up as ordered (see above) and proceed to give report. As a general rule of thumb, I always review the MD's orders with the receiving nurse. So the orders state "ice chips only until I re-check." What does Nurse Stupid do?? She asks the patient what he would like to drink! Even offers him Coke, Diet Coke, Sprite, juice, etc. I am astounded!!! The patient's wife is astounded!! Needless to say, the nurse was promptly corrected.

Another case of blatent stupidity occurred when Nurse Dummy gave a 2 month old infant a bottle of pedialyte in the PACU right after GI surgery. Boy, was that MD ticked off. (He had a right to be.) He made a huge scene in the PACU in front of all the nurses and the patients! Even the patients had looks of horror on their faces when they saw the tantrum he threw. (I think he would have been better off the have addressed the situation in a different manner as one of the patients was his very own. She couldn't believe that kind old Doctor would act in such a terrible fashion.)

To wrap this post up, maybe Doctor should imagine Nurse Dummy's face on that tennis ball and whack the crap out of it. I know I put a few faces on my tennis balls today!

Ever seen anyone with this expression?

I certainly have. I've seen this expression on many a face... doctors, other nurses, patients, or worse... the patient's family...

I've seen it on members of my own family including Husband, Son, and even (hanging head low here) myself. This is actually the expression I have worn for the most part of the day. Why? You might ask? Well, let me enlighten you. Sometimes it is not good to try to help an in-law out of an unfortunate financial situation. You can be repaid with the said in-law going out on the town enjoying life while you are working extra shifts to pay not only your own bills but to also try to keep a roof over their heads as well. Lesson learned.. never rent to in-laws! At least the in-law is not living under the same roof as myself! Okay, I'm through whining about this, moving on...

Patients.. for the most part I actually enjoy taking care of my patients. Pain control is one of our main concerns (after the ABC's you know.. airway, breathing and circulation) in the PACU, or Post-Anesthesia Care Unit. Morphine, Demerol, Dilaudid, and good old Phenergan (Versed if you've been very bad) can be a nurse's best friend. With the right combinations of these medications, you have the ability to significantly ease almost any pain imaginable. It's absolutely wonderful to be able to help someone in a time of crisis. Of course, there is the occasional crack-head, drug abuser or what-have-you that no matter how much pain medication you give them, it isn't going to help! Then they have the audacity to accuse you of not giving them any meds even after you have explained the reason that they are continuing to have pain.

One good thing about working in the PACU is the fact that visitors, as a general rule, are not allowed in the PACU. We are simply too busy extubating patients, monitoring the ABC's, taking care of vent patients, etc. to have family members asking questions or making demands on our precious time. The bottom line here is that the PACU is a critical care unit such as any other ICU. We are here for the patient first and foremost. Problems do arise when family members cannot understand the rationale behind it being a closed unit... they get the "expression."

More to come...

Playing nice...

Greetings all...

After reading many blogs by other health professionals, I have been inspired to start my own so that I may share the many insanely stupid events that I have had the strength to endure. No, I'm not kidding. Working in the PACU (aka the "recovery room") can be a rewarding, yet crazy, experience. You have the ability to help your fellow humans at a time when they need it the most. Some patients are great, others not so great... Some coworkers are great, others not so great.... some docs are great... well, I think you get the idea. Bear with me as I get this blog up and running. Feel free to comment any time the urge strikes....