Armed and Dangerous

I finished my 7th week off orientation yesterday. The time has flown by. This week I started to feel a little more comfortable, I was able to help the other nurses a lot more with their patients and be aware of what was going on around me, outside of my little two patient world. I feel more comfortable watching the other nurses’ patients when they go to lunch, and it’s nice to be able to walk down to the other end of the hall to answer a call light, just to see some different scenery.

I’ve had a few sick patients and a lot of busy ones. I survived my first three day in a row stretch of work where I ran my tail off for three days straight. I look at it this way, running across Death Valley is going to take 60 hours or less. That’s the same amount of time between the beginning of my first shift and the end of my third shift. I’d rather be running 135 miles across the desert in July, but I can look at 60 hours of work as an endurance event. That makes it more palatable.

I did have a lot of work nightmares this week. On my two days off between long stretches of work, I would take afternoon naps and I’d be having dreams about work during my nap! I dreamed of this one patient who died last week, and then there were other less scary but annoying dreams. I don’t want to be at work during my sleep if I’m not getting paid overtime!

I made it through assisting with my first arterial line insertion and a road trip to CT by myself. I also survived dealing with one of the doctors who likes to chew nurses heads off. She didn’t bite mine too hard but she does have this way of letting you know that you shouldn’t bug her about things she thinks aren’t important. Even though the hospital policy says we have to get a doctor’s WRITTEN order to do them. Her attitude is, we can use our nursing judgment. My judgment tells me that I need it on paper from the doctor, which means I need to ask her about it. Which requires verbal communication.

Last weekend I worked three in a row and I had this one anxious, impulsive GI bleed patient who had an insulin drip and hourly accuchecks, that is always enough to drive you crazy, just keeping up with their glucose every hour. He was on the call light every five minutes and he’d been in the ICU for a couple of weeks. He weighed over 300 pounds and didn’t move very well, so you’d have to recruit lots of other people to help every time he needed to be turned or needed the bedpan UGH! Everyone was tired of him and it was my turn to take care of him. I was so OVER IT every single night when I went home.

The first day I took care of him he drove me absolutely crazy. The second day when I came in we had a talk about the call light. It was not intended for use every time he wanted a drink of water. We set some limits on how often he could have a drink, since he was on fluid restriction anyway. It helped. I hoped he’d be out to the floor by the time I got back from two days off. He wasn’t, and I got stuck with him again when I came back Wednesday. But by then I was used to him and it was easier. You get attached to your patient after a while, in a way. I was glad yesterday when I didn’t have him, but it made it easier to help the nurse who did. We all cheered in report when we found out he had transfer orders.

The bad thing about the three busy days was that I felt like I wasn’t giving good patient care the way I want to, I wasn’t able to give baths or straighten the room, untangle the cords and IV tubing, or label everything the way I like to. That’s not important but it helps so much for the patient and their family to walk into the room and see the patient has clean sheets and a clean gown, is relaxed, had a bath, the room is not chaotic, the patient isn’t tangled up in all the monitor leads and arterial line and IV tubing.

Yesterday the charge nurse gave me an easier assignment. I only had one patient. He was really sick but it was only one patient and it felt like a gift. I needed it on my fifth day out of seven running my butt off.

I’ll call him Suppository Man.

He had a bowel resection, was really old and a DNR. He was not too aware of what was going on around him and he’d been on vasopressors. We were trying to keep them off but his blood pressure was still pretty low. I recognized that his CVP was low and I wondered if he might need some fluids. It’s nice to get to the point where you can think about simple things that might be going on with your patient. I assessed him and made notes for the doctor in rounding. He was in a lot of pain the day before when I’d helped his nurse turn him. He couldn’t tell me if he was in pain, he wasn’t oriented to much of anything. All he had ordered for pain were Tylenol suppositories. All of his medications that weren’t IV were rectal. Fortunately there weren’t too many, but more than I’m used to.

When I assessed him he couldn’t tell me anything. He did follow commands but he wasn’t answering my questions appropriately. His daughter was in the room and she helped me understand what he was saying. I asked him if he had any pain and he didn’t answer but he squirmed when I touched the area around his incision.

I got my ammo out of the Pyxis.

The dreaded Tylenol suppository, wrapped in foil, every 6 hours.

The silver bullet.

I always use the double glove method. There is no way I am sticking my finger in there without extra protection. I found a tube of surgical lubricant, in the drawer, squeezed in the middle and almost empty. Obviously someone had been using it a lot. I was about to ask the unit assistant to help me turn him but it was chaotic by the nurses station. I decided to try the approach from the front, to see if I could get it in without turning him before he got some pain relief. It worked. I went back to the supply room and got a whole new tube of KY jelly. It was going to be one of those days.

I got my assessment done and was trying to figure out what Suppository Man was going to need when the daughter came out in the hall and got me. He needed the bedpan. I came in the room and he was pointing toward his genitals. I asked him what he needed, he mumbled “have to go”. I turned him as well as I could by myself and he didn’t scream. I stuck the bedpan under him and rolled him back. I hoped the Tylenol got a chance to get absorbed before he pooped it out.

Suddenly his heart rate dropped down to 48 and the monitor started alarming. He was pooping. That’s one thing I have learned, you can often tell when your patient is pooping because they vagal down to a lower heart rate. You can tell when you’re at the nurses station looking at the monitor if you’re waiting for your patient to use the bedpan! My patient did poop, which is a good thing after a bowel resection. It was looking like it would be an easy day.

During rounds the doctor thought my patient needed fluids, he ordered a bolus and then upped his fluid rate. The doctor was happy to hear the guy was off Levophed which was the vasopressor they used overnight to keep his blood pressure up. I got him going with the fluids and things were fairly calm. Then the patient across the hall started alarming. I went into the room to check him. He looked okay but he was sleeping. I thought maybe he knocked his leads off since he was so tangled up. His nurse was in rounding. All his leads were on and he was snoring so I reset the EKG box and went back out in the hall.

A few minutes later the asystole alarm went off in his room. I went in again and the numbers were all reading zero or weren’t picking up a signal. The guy was rolled over on his back and not moving, it didn’t look like he was breathing. I shook his wrist and called his name and he didn’t respond. I grabbed his wrist and couldn’t feel a pulse and he still wasn’t moving. I knew I’d just checked the leads and didn’t want to waste too much time, I didn’t see anything knocked off and he still wasn’t moving. I ran out in the hall and yelled “I need help in room 12!” I went back in and started to feel for a carotid pulse, which I should have done in the first place. It was hard to find but it was there. Two nurses came running in. The guy was still not moving, and his nurse yelled in the guy’s ear, WAKE UP! He had sleep apnea and was hard of hearing, and was sleeping like a log. His nurse told me, “Sorry, I should have told you he has lousy pulses.”

Scared the hell out of me. I was shaking. I felt really dumb for yelling for help but the guy was okay, sort of. I wonder if he hadn’t alarmed on the asystole alarm how long he would have been lying there not breathing.

I got caught up on some charting and then my patient’s alarm started dinging. It was his blood pressure. I had the bolus in and upped his fluid rate but his blood pressure was hovering around 90 and I didn’t want to start the Levophed again. I started to try calculating a drip factor on the Levophed and for some reason my brain was having a hard time calculating it right. I thought I’d go ask the charge nurse to check my numbers and be ready in case I needed it. I checked his arterial line and did a cuff pressure and he really was low. I went out the desk and told the charge nurse I thought he needed to be on Levophed again. She said to go ahead and start it again. When I checked the orders earlier I saw that he had an order for a dose of 2-20 mcgs.

I went back into the room and started the Levophed on the smart pump with the lowest dose. Then I started to check my numbers with the drip factor and his blood pressure shot up so fast the high alarm started dinging. He was at 225/125 before I had a chance to punch a button on the calculator. I knew something was wrong so I shut the pump off. I should have had the charge nurse to check my numbers before I went back to start it. His pressure came back down as fast as it went up. I was shaking. I stood there until I knew he was staying at a reasonable pressure for a few minutes. Meanwhile the patient’s daughter was in the room watching everything and seeing the numbers and hearing the alarming. As soon as he stayed around 85 I went back down and got her to come back with me. She said, “I haven’t done this in so long I can’t even remember it.” At least I wasn’t the only one.

She figured out the drip factor, and I got that right, but then I realized I was looking at the wrong line on my little card. I was looking at the line that said 2-30 mcg but it was Dopamine, not Levophed. I told her that. She asked me what the order said and I told her 2 to 20 mcgs. And then when she looked at the pump she asked me what units it was. I said, micrograms per kg per minute. Then she said, “Who wrote the order?” I told her the doctor’s name. She said, “That’s why!”

It was the other doctor, the one who bites. She is the only one who writes orders for vasopressors in those units. Everyone else writes the doses in the same units as the pumps, the way we’re supposed to do it. I was using her order which was in mcg/min when we need to use mcgs/kg/min which is how the smart pumps are programmed. What I had done was programmed the pump to about ten times the dose he should have been getting.

After we got it set up correctly and watched his blood pressure go up to about 100, we went out in the hall. I was still shaking. I said that scared the hell out of me. The charge nurse said, we’ve all done it before. She said they have tried to get that doctor to change the way she writes the order but she won’t change. I do remember hearing something during my orientation about one doctor who writes the orders in different units but of course I didn’t remember who or what it was about. Now I won’t forget.

Smart pumps.

That was enough excitement for one day. I had the Levophed on and had to start titrating it down but pretty soon his pressure dropped again, so I’d increase the dose. The doctor finally got around to my patient, I think he was last. He decided Suppository Man needed some albumin instead of just a fluid bolus so I got that started. I was hoping his pressure would stay up so I could turn off the Levophed after a while. It never happened. By the end of the shift I had him on the minimum dose of Levophed and an albumin drip. But he was becoming more oriented and when I asked him where he was he told me I was the doctor.

And he had five suppositories all day which was five more than enough for me.

I did get to give Suppository Man a bath, untangle his cords, label the pumps and tubing, clean up the room and got everything looking uncluttered and calm before his daughter came back in the afternoon. The surgeon came in and thought he looked okay so we didn’t need to go on another road trip to CT. I spent the last two hours of my shift checking blood with another nurse and taking care of two of another nurse’s patients so he could do his charting.

I went home and scrubbed my hands a few times, with extra attention to my right index finger.

I have four days off. We are going up in the mountains, to let the mountain air to get the smell of GI bleed poop out of my sinuses…

Peace, love & double glove,

Towanda, ICU RN