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