Week 2 Shift 3

Today I worked at my other facility, where I used to be a full-time night-shift ICU RN and am now working per diem shifts on days. This hospital and I have some bad blood because their method of handling conflict and "incident reports" involves a lot of stewing and poor communication. Like I might be a bitch to that CNA I chewed out, but by fucking god I talked to her about it, and after this I plan to discuss it again after a few more shifts with her (to see if our initial agreements smooth things over) and if necessary seek mediation from a higher-up. ICUs have too much shit going on to let drama grout up the corners.

This hospital and I also have some very fond memories, and I still work PRN there because I would miss the staff too badly if I really left. They have some good days.

Just as I have some bad days. Today wasn't, like, incredibly bad, but I did three major embarrassing things, which I will explain to you in due time.

Today I was floated from the ICU (the shift I signed up for) to the SCU, the special care unit (aka telemetry). This is not a problem; SCU is great and the people there are, for the most part, lovely. The level of care is lower, but (in my humble opinion) not low enough that the pt-to-nurse ratio of 4:1 isn't a complete nightmare. SCU nurses work so fucking hard it's ridiculous, and this is coming from a person whose job sometimes involves cramming her whole hand up a fat guy's ass to dig out all the little pellet poops. So a float there is a serious nursing workout with a strong team, and I really enjoy it.

One of my pts had undergone atrial cryoablation yesterday-- his heart wouldn't stop going into rapid atrial fibrillation (I will have many more opportunities to explain this in-depth, so I'll just say "fast irregular heartbeat" for now) so they burned away the angry chunks of nerve inside his heart with a balloon full of liquid helium. Today the plan was for him to discharge home. He had absolutely minimal needs as a pt and honestly there was a space of about an hour where he was asleep after lunch and I forgot about him. His ride home wouldn't be available until after 1700 anyway.

Another pt also had a-fib, which he had gone into because of the stress on his body from pneumonia. He was an absolute dear and his heart rate was well under control by the time I picked him up-- still irregular, but not speeding out of control. His care was unremarkable-- giving meds, giving breathing treatments because the RT was swamped, and charting.

Speaking of charting, the best thing about working at this facility is that we use Soarian, which is probably the third-worst charting system in the medical world. Soarian is made by Siemens—a German company that has its roots in WWII, when parts of its monopoly were shut down for war crimes involving “using concentration camp labor” and “using that labor to make gas chambers.” The point is, there are few things more satisfying when you’re sick of charting than calling your system a “piece of nazi crap made by literal hitlers.”

The third pt (this unit often assigns four, but today I only had three) was a comfort-care pt preparing to go home on hospice, an incredibly unfortunate old lady with a history of stroke that had rendered her aphasic. She was in for a horrific fungal epidural abscess that was not responding well to antifungals, plus a giant left-thigh abscess that left her in tremendous pain. The pt's two daughters were sweet but anxious, struggling to get their brains around the skills and information they would need to bring their mother home to die, not really quite understanding that the hospice nurse would be taking care of most of it. Bonus: a stepsister was also in the picture, but we were not allowed to give out any information to her, nor was she allowed to visit. Apparently she suffered from "being super crazy" and liked to pick screaming fights with the dying woman. This resulted in some tense phone calls with the estranged stepsister, who wanted to come see her mother "before she had a chance to work things out," but who claimed that she couldn't possibly come visit her once she was on hospice (that is, with the daughters both at the bedside). 

Pain control was the biggest issue. We needed to get her pain under control, and we had to test out the oral medications (fast-absorbing mouth-dissolving morphine tablets under the tongue) to make sure they worked sufficiently. It ended up being a tremendous parade of too much, too little, too much, not nearly enough. I hope they get it worked out soon, so she can go home before she dies. 

While I was applying a lidocaine patch to the area around her abscess, an older woman came in, well-dressed and well-groomed, and was immediately moved to tears by the dying woman's condition. "You've been through so much," she said, and helped me arrange her pillows to accommodate the lidocaine patch application. She watched the process with interest, so I did my usual thing and started educating. I explained that we were applying the patch to give local relief of pain, which would sort of overlap the central relief of pain offered by the morphine and the fentanyl patch, and hopefully give her better pain control.

The woman was looking at me very strangely by this point, and looking confused as hell. Undaunted, I plunged onward in my usual progression: if the student is still confused, use simpler language and more accessible metaphors. "This medicine is like the stuff you put on a toothache to make it go numb," I said, and she cut me off.

"I'm Dr. Novak*," she said. "Her clinic doctor. I'm not wearing my badge right now, but I do know what lidocaine is."

I stammered an apology and turned red to the ears, then remembered to give it a decent spin and managed to flutter on about how, not knowing who she was, I was just instinctively giving her the same education the pt and her family were receiving. She lightened up a bit at that, but I had a few minutes in the supply closet gathering myself back up.

Then at three they had me give up my pts and pick up two actual ICU pts next door, because one of the nurses was going home.

I picked up a developmentally-delayed woman, an ex-Special Olympian who had been coming down with increasingly frequent cases of aspiration pneumonia. The plan is to make her a diverting tracheostomy-- completely separating her esophagus and trachea so she can never choke on food again, and breathes entirely through a stoma-- on Monday. We extubated her at the beginning of my four-hour shift with her, and she was very unhappy about that. Fortunately she was one of the lucky souls who responds well to Precedex, a completely imaginary sedative that usually just serves as a self-extubation in an IV bag, but which occasionally is very soothing and sedating to certain folks. I left her on a little of that and it worked like a charm.

Unfortunately, about an hour after extubation, she had so many oral secretions that we had to nasotracheally suction her: a thin rubbery tube inserted down the nose to suction out the trachea. Try as she might, she just could not swallow the stuff, so she was choking on it. I held her hand and soothed her as best I could while the RT did the job, and stayed there patting her forehead and shushing her for a while afterward... until the RT explained to me that the one thing the pt hated more than anything else was having her head and face touched. Well, fuck. Strike two.

Strike three came when my successor dropped by from SCU and explained that the atrial-ablation lady had been given some kind of weird communication-only discharge orders at noon, and I had just missed them because they were comm orders instead of actual ORDERS. Fortunately I had already done most of the discharge work, and it wasn't quite five yet, so nobody was inconvenienced.

The other ICU pt was entirely unremarkable except that she was convinced that every hospital has "at least one nurse who's killing all their patents." I tried to soothe her fears, but for a moment I felt like that nurse, considering that I'd made so many mistakes today.

A frequent flyer at this facility came back today, a woman who tries to leave AMA (against medical advice) almost every admit, and can only be convinced to finish dialysis by bribing her with pain medications. She has had multiple revisions of her AV fistula (a surgically-created site on the arm where arterial and venous blood come together in a single huge vein that bleeds easily) due to poor care and her general failure to show up at dialysis on time... which causes her to be readmitted to the hospital regularly, because toxins build up in her blood and she calls 911 as she's starting to feel really dangerously sick. She has a grotesque circumferential surface leg wound; the doctors are at a loss, and have suggested several times that she just go for an amputation. She is a sex worker, somehow, even with that reeking leg wound, multiple transmissible diseases, and general appearance of somebody slowly pickling in nitrous waste from the inside out. I don't think she's very happy in that career.

This time she had, again, nearly died of being un-dialyzed. Her leg wound had spread significantly; she'd been totally noncompliant with diabetes care since her discharge, and was really upset because she had shot up in her AV fistula and it wouldn't stop bleeding. They removed her homegrown dressing and instantly the whole room and half the hallway was covered in blood. She got a surgical re-revision of the thing.

Also, the fire alarm went off today. Some old person in Geropsych must have pulled the fire alarm. That is two buildings away so I wouldn't care if it burned to the ground.

Okay. Two more shifts this stretch (Friday's is only an eight-hours). See you on the flip side.