Thursday, July 9, 2015

Week 1 Shift 1 (technically five of seven)

Let me tell you about my days.

Today I took report initially on one pt, a man with a neurological disorder that has left him wheelchair-bound and epileptic. Recently he seized during a wheelchair transfer and broke his hip. Now, after hip surgery, he remains unable to swallow, massively incontinent of urine and stool, and extremely forgetful. He wants oral swabs soaked in water, because his mouth is dry-- we are giving him IV water and food, but this doesn't keep your stomach from growling or moisten your throat-- but he can't remember when he's had them, and he presses his call light every twenty seconds. I almost never take a call bell away from a pt, but I took this one away. I feel vague guilt, and also this increases my workload since I now have to ask him every fifteen minutes if he needs anything. The answer is always "swab." I can only give him one every thirty minutes; he chokes on even that little bit of water.

I attempted to start a feeding tube earlier but it just made his nose bleed, which kept me at the bedside suctioning him until the bleeding stopped so he wouldn't choke. That can take a while, since you can't put pressure on the bleed.

Meanwhile, took an admit from an urgent care clinic, a little old man whose heart is too slow (bradycardia). He will get a pacemaker today. However, the night doc was caught up in a Code Blue, and failed to put in ANY orders before staggering out of the hospital to (I'm guessing) die quietly in the parking lot of exhaustion. The day doc had no time to put in orders for a full 1.5 hours after admit. I just started dopamine and crossed my fingers, as the urgent care clinic had already tried atropine.

Paging the night doc got me written up. My initial response was not exactly polite, but hey, a thirty-six-hour shift will make any doc kind of cranky.

The rest of the shift was fairly uneventful. The old man's heart converted back to a more stable rhythm (sinus bradycardia is better than junctional bradycardia) so they're holding off on his pacemaker until tomorrow.

The neurological disorder guy just made me sadder and sadder. His brother brought in his dentures so he could chew food, even though he can't even swallow his spit. He constantly begged for water, but choked on even the few drops from the mouth swabs I gave him every thirty minutes.

A little investigation revealed that he's been on hydrocodone every six hours for the last thirteen years, but since admission hasn't received a single pill of it-- or any of his psych or anti-seizure meds-- because he couldn't swallow after surgery. Whether this is because of advancing neurodegenerative processes or because the intra-operative intubation process damaged his throat, he stil needs the damn drugs. Plus he had fucking surgery, he needs pain meds. I threw a fit and got IV morphine, then finally got it switched to a PCA (patient-controlled analgesia) pump so he could dose himself at need.

The dentures were time-consuming. They had to be cleaned and stored, the container labeled, their presence noted in the chart, etc etc. Paperwork.

Another nurse asked if I could do a sign-off with her. This facility requires sign-offs on all cardioactives, sedatives, and electrolytes, in addition to the universal two-RN blood sign-off. Her pt looked shitty, pale, drenched with cold sweat, and gray-mottled all over. I hovered for a few minutes while she listened to the pt's chest for some fucking reason, waiting for my chance to sign off on whatever drug or bag of blood she needed me for.

Then she nodded briskly, walked back to the computer, and entered all this into the "clinical death" flow sheet. Fuck, okay, no wonder the guy looked bad. Guess we were just hanging out with a dead body.

The reason I had to sign off on the pt's death is that apparently once an RN had a dying old person hauled off to the morgue before their heart was quiiiite done. This is easier than you might think, because the heart keeps slight electrical impulses for a while after death, and a weak pulse isn't always palpable. So two RNs are supposed to listen to any dead pt's chest for two minutes straight to make sure we can't hear any beats (ie valves closing). I mean, at the point where your heart beat is debatable, your brain is getting no perfusion and you are already brain-dead, but recent corpses do enough weird shit like breathing and farting that it's a bit much to risk em having a heartbeat as well.

Not that I actually listened, since I had no idea the guy was dead. If I had been reading off blood or checking a drip that had a chance of hurting a living pt, I would have had to go back and check the whole thing... but honestly, if I know you're a decent nurse and you tell me your pt is dead, and I've been standing there for five minutes and not seen them breathe at all and noticed that they look like three-day-old waterlogged ground beef, I'm probably going to trust your assessment.

Cleaned up, gave report, drove home, passed out. Tomorrow will be day six of seven, and I'm tired as shit.

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