Internet Medicine

Alright! I've had enough. I love my patients, I really do, I don't even mind the med students, they're fun, you get to mess with their head. But really people, do you think you can get all of your medical information from the internet???

Every day it seems we have pts convinced that they have some disease or another (mind you there in the ICU because of a stroke) and yet they don't listen to you when you tell them that they have diabetes. "Oh, I don't believe in that stuff." or the best "WebMD never said anything about that." It's great, you have to bat your college degree and the docs skill against the internet. It's a game of "How fast can you google??"

Part II, last week I caught a med student looking up a procedure on Wikipedia before he preformed it. Yep that's right folks, he was using Wikipedia as his source of medical knowledge. To say the least I pulled the equipment out of his hand. Not on my pt thank you!

Anyone scared yet??

Nicknames

So a pt recently gave me the nickname The Elf (I swear I'm not THAT short) and it got me thinking about the different nicknames that we earn and the people that give them to us. A lot of times it says something about their personality and your relationship. My sister calls me by a rather endearing nickname, but I would never let anyone else call me by it. Just doesn't fit into any other relationship.

Anybody else have insight on nicknames?? Or is this another dose of 2am madness?

The Night Beat

Wow, long time no posts. Well, I'm officially on the night shift, nothing screws up your mind more then seeing the sun just before you go to bed....it's quirky, I feel like I'm living in Alaska. Plus things get pretty quirky at night. Crazy stuff happens at 3am when no one is around ;-)

One of the most challenging things about nights (you'll probably laugh at me) is that at 6am the residents do their rounds. Now normally I really like rounds, I like giving my input and filling in the gaps. But at 6am when you've been up since 4 the day before you barely know what day/month it is, let alone what's been going on with your pt. The docs will ask "What feeding are they on? Rate? any respiratory problems last night?" Well, I can answer the respiratory with a big fat YES! Other then that, I have no idea, you can feel free to look at the pt/the feeding pump yourself. I'm always really proud of myself when I have answers at 6am, probably shouldn't be, but alas.

Anyway, over the past two weeks I feel like I've been getting the hang of things, I actually know where an a-line setup is in the Omnicell (a major accomplishment when the a-line dart is filed under internal catheter dart...and that is the one that makes the most sense..The Swan Gaunze is filed under Swandome...hmmm) and I can set up an EVD in less then 20 min (always good).


3 More days of orientation, then I'm all on my own, Hopefully I'll hold my own, I'm thinking I will

Realization

I am a new nurse. Just a small fact that you may or may not have figured out about me. So new in fact that I have more "Am I really a nurse?" moments then "I'm a nurse." I usually find myself walking into my patient's room and saying "Hi, I'm E." the whole "and I'm going to be your nurse today" I end up saying in my head. This is all very important to understand to understand what I'm about to say.

I live in Big City. So I go to Big Church. Where I hoped to meet non medical folk. I ended up meeting 2 medical students who are probably 3-4 years older then me. (I'm a young'n what can I say) Said medical students go to Big Medical Center where I work....odd. Anyway, during the day and conversations that I had with them, I realized. I've only worked at Big Medical Center for 3 months (they've been there for 3 years) and yet their treating me as their superior. Asking me my opinion on things, how we do things on our unit.

After this I realized that the residents and attendings at Big Medical Center have started treating me as their equal too.

It's a bit odd....It's great, don't get me wrong, but when you haven't come to terms with your new status as a nurse and everyone else seems to have come to terms with it, it throws you for a loop.

Anyway, things generally are going great. I have bad days, really bad days. But even after the bad days I realize that I still love this unit, I still love neuro and I wouldn't trade it for the world. The best thing is that I have really good days too. And I'm starting to feel like I fit in on the unit. Who knew that that would ever happen? That my quirky personality would fit in somewhere???? Alas

Best Moment

Everyone always talks about the best moment that they have had in medicine. This week I've been thinking. I've had a rough couple of weeks. Each week I've had at least one brain dead or almost brain dead pt. D/cing care is hard, family is tricky, I never know what to say to them and the docs never seem to say enough, or they don't speak clearly about the situation. So we're left with the questions.
Anyway, the point is that I needed a good moment. What I didn't know is that I would get one of the best moments one of the best thank yous I've ever gotten.
I'd had this pt who was paralyzed and we had to put a trach in, so she couldn't speak, but she was totally aware. It was really hard on her. She would try to mouth words to us to tell us what she needed. I worked so hard to figure it out, sometimes I got it and sometimes I didn't. The days I had her were rough, I could see the frustration in her eyes, but we never gave up. Well, last week they capped her trach. I didn't have her that day, but I went in to say hello. Little did I know that she would say hello back. We both started tearing up and she just started saying "thank you, thank you"
It was a thank you that I never needed, but hearing her voice was the best moment that I've ever had. It was wonderful and something I never want to loose.

Tip of the Day

Today's tip: When transferring a patient from another unit (whether it's an outside hospital or inside hospital transfer) to a neuro unit...GET A NEURO EXAM! It's easy, promise a good neuro exam can take you less then 5 min let's go through it step by step...

1) walk into the patient's room, see if they open their eyes when you walk in (tip: give neuro pts, at least 30 secs to respond to anything you do, and 30 sec is longer then you think!)
2)if the pt doesn't open their eyes, say hello, introduce yourself and explain why your there, see if they open their eyes.
3) if they still haven't opened their eyes you have to move onto painful stimulus, this is what scares new nurses the most. Just remember if they need this, they need it, you're not hurting them to hurt them.
Tips to giving go stimulus: avoid the sternal rub if you can, to do a good rub you should leave your nail marks on your hand and a bruise on their sternum (get the picture) There are better places to produce stimulus. My favorites: Take a 1 1/2 inch pinch of the trapezius muscle (grabbing muscle, not just skin) and twist (try this on yourself it hurts.

4)if after giving painful stimulus (try multiple types in multiple locations) they haven't opened their eyes, you can say that they aren't responding.
5) next, look at their eyes. This may mean opening them yourself. Take a penlight and see if they react. A general rule of thumb that the neurosurgeons go by is that if they have pinpoint pupils they may be sluggish, but they cannot be fixed.
6) Check for movement in all extremities. If they're not moving one limb or one side, first ask them to look at that limb and move it, if that doesn't get a response pinch that limb and see if you get a response. Again, if they need a pinch to get moving, you need that information.
7)If they're moving everything and following commands there are a few more things that you can have them do, if not you may have to stop at this point.
8) ask them to take your hands and pull you towards them, push you away, this will give you an idea of arm strength
9) ask them to lift their foot off the bed and keep it up as you try to push it back down onto the bed, do the same on the other foot
10) have them stick their tongue out at you (some pt enjoy trying to touch their tongue to their nose as well, and it makes them smile which gives you a good idea of facial symmetry)
11) have them give you a good cough, take a sip of water (not necessary if you're short on time)


See it's easy, now let's see what info we have gathered.....You've been talking to them, so you know speech status, you know PEERLA, strength, you may know orientation, you have successfully assessed their motor function and their consciousness!
Not knowing the exact size of their pupils, or the total Glasgow Coma Scale score, EOMs, sensations aren't a huge deal, any neuro nurse will be grateful that you took the time to do a simple neuro exam and that information is going to allow us to be prepared for what is coming!

The exam may look long, but trust me, it is simple, it just takes a bit of practice and you'll have your style down, before you know it you'll be assessing neuro status on the fly in the grocery store!

OSH

So here is that story....this may or may not be true, all names have been changes ect. in accordance with HIPAA.... yadda yadda yadda

So I took my very first outside hit (OSH) on Friday. A hit is any patient that is sent to us from an outlying hospital when they decide they can't deal.

I'm talking to the nurse over the phone and the conversation when a bit like this::

Me: "Hi."
OSH: "Hi."---pause for 2 min to cough--"sorry, I should be home now."
Me: thinking...yeah, you should, stop coughing on my patient! "what do you have for us?"
OSH: gives various details..."Patient became combative, brought into the ER, we intubated."
me: thinking...you intubated an alert patient...hmmm.."What are her vent settings?"
OSH: "O2 100%" gives various other settings
me: "100%!, is a PEEP set?"
OSH "no PEEP"

::time out:: realize that at this point my head is screaming, you did what!!!!!!! my preceptor is frantically looking between me at the attending who is standing over my shoulder (nerve wracking..a bit) trying to figure out what is going on and what we should do
Back to conversation

Me: "Access?"
OSH: "Two PIV, one with 0.9NS, one with D5W and propofol"
Me: "Turn off the D5w" (don't worry, I had an order)
OSH: "our pharmacy says you have to run D5w with prop"
Me: "if you have to turn off the prop to turn off the D5W that's fine, but turn off the D5W"

::time out:: at this point you have to realize something about neuro, something I didn't know until recently and then maybe you'll realize my frustration. The brain likes glucose and water, so giving it D5W is giving your brain directly the fuel it needs which in theory is good. In practice it means that the cells in your brain swell up. So any edema that the patient is already experiencing can be doubled by giving them D5w.

Me: "Any neuro exam"
OSH: "PEERLA"
Me: "anything else?"
OSH: "she's medically paralyzed."
Me: "no exam prior to that?"
OSH: "Don't know, she wasn't my patient."



WHAT????!?!?!?!?!?!?!
Are you kidding me?? I'm getting report from somebody that didn't even have this patient? Wow, that is something..To say the least we got the patient to our unit ASAP and got the story straightened out.....It was an interesting experience.
Most the unit was laughing from the time I hung up the phone until the patient rolled up, it wasn't particularly funny, just trying to deal with another bad situation.

Gotta love it!

Politics and Infection

I swear that not all posts will be bitch rants...but this needs to be said. I don't think I'm the only one with this problem, so here it goes.

So I work in an ICU, but my situation is a bit unusual because we often have patients for anywhere from 2-21 days. It's not uncommon for us to have a patient on average of 14 days, but recently we have had 2 (count them 2) patients for more then 8 weeks! Not because they were sick enough to really need ICU care but because they had ventilators and because of those ventilators they needed to be suctioned...anyone see where I am going here....

So when it comes time to transfer them the conversation goes a bit like this...
floor nurse: "How often do they need suctioning"
ICU nurse: "PO every hour to prevent VAP, inline suctioning Q2hours and PRN"
floor nurse: "Well, we can't take a patient that needs suctioning more then Q2hours."
::conversation over::

So now here is the problem, they're leaving vent patients on the ICUs where they are more likely to get nosocomial infections including VAP because the floor nurses are refusing to do what is necessary to prevent VAP. And because the floor nurses aren't taking the vent patients there numbers look better and we're the ones that are getting yelled at for infection rates, not them.

Not to mention that patients that don't need ICU care are taking up our beds (not that I don't like them) and we have to turn patients away from other hospitals that can't take care of them!!!!) ---another story for another day...just remember for you non-neuro people, NEVER GIVE D5W to a neuro patient when you suspect cerebral edema, I don't care if you're giving Propofol or not!---

Now I get that the floor nurses have more patients then I do and usually only go into a room every 2 hours, but how hard is it really to walk in an do some PO suctioning to get out excess secreations??

Rant over...for now....

Nurses's Bill of Rights 2

So the last post got me thinking...what if we really did have a bill of rights posted up next to the patients rights...what would it say??

There are things that I've begun to give up or change because of family, doctors, or just plain lack of time.

Bathroom breaks is a big one. Who has time to go to the bathroom?? I'm lucky if I sit down to do charting most days, let alone sit down on a toilet....hmm maybe if I could take the chart into the bathroom, be productive.....interesting thought.

Eating is another....I'm not saying that I don't eat during my shift...12 hours is a long time to go without eating, but you feel guilty for taking your hour break for lunch. The looks you get from family. It's as if they're saying "how dare you eat when my mother/sister/father/grandfather/brother/daughter is in that bed sick." Even when you step into the breakroom for a quick bite you get looks. I stopped in the nutrition room today and shoved a cookie in my mouth, cause it was a cookie and good, but also cause I was STARVING and got caught by a family member. I wanted to say "I NEED TO EAT TOO YOU KNOW!"

It's also as if there is an unwritten code,....No laughter may enter these doors. Well, sorry, I'm a lively person, I am boisterous, fun, obnoxious, I occasionally (more then occasionally) dance without any music, and I talk to myself....I laugh too so there! I feel for you and your family, really, but this is where I work and I love my work, I'm just showing you that I love my work.... :-P

So my bill of rights would look something like this:
1) Toileting q6 and PRN
2) We get to eat when you eat!
3) We laugh, joke and smile, it doesn't make us bad people


hmm...can we get an amendment in there about carrying coffee around..that'd be nice, maybe in one of those camel-backs....hmmm..thoughts for another day.

Nurses's Bill of Rights

(I found this and though some would be interested)
1)The right to void at lease once in a twelve hour period
2) the right to carry crackers for glucose levels under twenty
3) the right to a cup of coffee without the consistency of Pennzoil
4) the right to use a non-black pen.

Things I've learned since staring in the NeuroICU

1) projectile vomiting, while bad, is fun when the patient can hit the med students

2) always give the patient a 6 for motor (follows commands) when they flick you off after asking them to show you two fingers

3) At least once a day check that the patient hasn't written down the answers to "Can you tell me your name? Do you know what day it is? Month? Year? Do you know where you are?"

4) When your 80year old patient propositions you, just take the opportunity to assess their speech and compliment yourself on not getting any bodily fluids on your scrubs

5) give your patient extra points when they correct you after you've told them the wrong date, even though you've written it down 10 or more times already

6) Listerine strips were made for "neuro breath"

7) Some patients look at bed rails the way Hillary looked at Everest, but in the end the rails just give them extra height to fall from.

Halfway through

Well, I'm halfway through orientation. I wasn't sure I was ever going to make it this far. Don't get me wrong, this is my dream job. I'm a neuro nurse, frankly deep down, I've always been a neuro nurse. I love autism, seizures don't bother me, and I think the brain is just down right cool, but ICU, that was scary. How was I about to help these people when I barely knew what was going on with them myself. 7 weeks in I can safely say that I'm a pro at a neuro exam and can correctly identify the 3 medications every patient is on. I even with fight the docs when I know that something is wrong, despite what they see. But family, overwhelms me, that look of fear and question in a patients eyes when they're intubated and can't speak, I don't know where to go, who to go to. I got lucky, my preceptor is great, but there is a lot to feel out. You don't always know which family members you can talk to and if the patient is the one making medical decisions, well, you can't talk to family unless you have permission from the patient, which is hard when they're intubated....things get tricky....HIPAA is always on your mind.....passwords, lists of permissible visitors, family spokesman...these are all the things that I struggle with....forget the A-lines, EVDs, CPP, CVP, MAP, K, Mg, Hgb, PTT, INR.....Those have structure, they are predictable, FAMILY IS NEVER PREDICTABLE