Thursday, November 6, 2008

New Nurse Insanity

REFLECING ON: Why working as a new RN is nuts on my floor. I can't believe a year ago I was a student.

I've been remiss in writing because, well, I've been absolutely going bonkers (in a good way) since getting hired as a new nurse on a cardiothoracic floor/telemetry unity. What's that mean? It means I get patients that are so sick that we monitor their heart and oxygenation 24/7. It means that our patients are WICKED unstable: recent/ongoing heart attacks/unstable angina, unstable heart rhythms (including V-Tach/Rapid uncontrolled A-Fib, heart block, and pacemakers), heart transplants, lung transplants, double heart/lung transplants, profound vascular disease requiring amputation, and a general hodge podge of rare diseases that academic hospitals get sent because nobody else has the resources to treat them. People code on my floor. We send a lot of folks to the ICU. We get a lot of folks from the ICU. I work 3 12-hour shifts a week, which I realize initially sounds pretty cush, but when you see the actual schedule and do the actual work, it's more like a 16-hour day of non-stop running. Here's my day:

-Wake up and stumble to coffee maker.
-Become conscious, realize have clothes on; don't remember dressing. "Neat", I think, "I'm efficient even when I'm semi-conscious." Double check that I have stethoscope, ID, PALM, a couple of power bars. Double check that I actually have pants on. Kiss wife. She murmurs through morning breath that she loves me. I tuck her in again and make sure her alarm is set for 0500. She will get up as I leave to study for the BAR. I want a day off. "It's okay", I remind myself, "I love my job."
-Review lab values/pharm/diseases that I've never heard before but nonetheless will be required to manage and speak intelligently on to patients, their families, fellow nurses, MDs (R1-R3, and maybe an attending), RTs, OTs, PTs, PCAs, PSAs, radiologists, and of course, my boss and nursing students. I drink a Liter of protein-shake straight from the blender while doing this.
*0500-0545 :
-Drive to SF, find parking in one of the neighborhoods around the hospital that ISN'T 2-hour, so that I can save $20. Remind myself that the 15 minute walk to the hospital is worth it. I may be finally making a paycheck, but I also remind myself that I'm still $75,000 in school debt.
-Walk to hospital, listen to iPod, consider second cup of coffee and perhaps going to Mexico where ephedrine is still legal (kidding). Try to breathe. Get semi-religious and pray a bit. The prayer is always the same: "Please Gods (I pray to all of them to cover my bases), give me the strength to act in the best interests of my patients. Allow me to act decisively when I know and ALWAYS seek help when I don't. Keep me and my team safe. Thank you. Word. One love. Amen." I breathe in fresh air one last time before entering into the hospital. It is usually smoky because the entrance is next to the smoking shelter.
-Arrive on hospital unit and sympathize with my night shift homies. They all are bug-eyed and slightly delirious. They openly wonder why the hell I'm there so early. They then get scared and start doing what they need to do before end of the shift. They don't understand why I am so early. I've been an hour early every shift since Janurary when I was a student on this floor. I am still early after working for 3 months. I don't intend on changing. This is my way. Don't knock it.
"No, but seriously, Nat, why?", they ask.
"This is what I do, don't worry about it and dismiss me as nuts", I say.
-I need to catch up on my patients and read new admission histories. I get to the computer and start reading about my assignment. (I am going to write the hospital jargon abbreviations next to the common ones so you can learn to interpret medical-ease) I review the assignment. It's heavy. I look at other folks assignments. They're all heavy. Okay, here we go:
-Patient (Pt.) #1: 47 year old (yo) female, status post (s/p) lung transplant (lung tx) 2/2 pulmonary fibrosis (PF) presenting with (p/w) shortness of breath (SOB)/wheezing/Chest Pain (CP) secondary to (2/2) Cytomegalovirus (CMV) infection. Right upper lobe (RUL) has SERIOUS wheezing. Pt. refuses oxygenation because prior to her tx, she was on a high flow mask that covered her face for 6 months while she was waiting for the lungs. @ 0900 she will be receiving a $35,000/dose immunoglobulin (Ig) that I will eventually have to do battle with pharmacy to get in on time, and then figure out how to administer because even veteran RNs have only given it once in their careers. I pray I don't drop the bottle. Later, after successfully administering it, I kid the patient and tell her that she is $35,000 richer. She laughs and thanks god for health insurance. I think of folks that don't have it. I then call pharmacist and kid that I dropped the bottle. Pharmacist takes me seriously. I let moments of awkward tense silence pass on the phone, and then admit I am joking. "That was REALLY not funny", she groans. On paper this is my least stable patient, but in reality, is my most stable patient because she knows SO much about her own treatment. I listen to her and try to coordinate appointments and medication administration around her work, which she still manages to do from her hospital room. She had had 7 hospitalization in the last 11 months, some lasting more than 2 months.
-Patient #2: 80 y.o. male s/p right lower lobe lobectomy (RLL lobectomy) 2/2 adenocarcinoma metastasis. Right Chest Tube (CT) in place draining 10 mL of serosanguinous (SS) fluid/12 hours. She's post-operation day (POD) #3. CT will probably be pulled today. Pt. also has history of (h/0) going into rapid uncontrolled atrial-fibrilation (A-FIB) (HR 180s) and becoming hemodynamically unstable (BPs: 70s-140s/40s-100s). This is in the context of NO prior cardiac history. Apparently when you mess with the bull (lungs) you get the horns (heart). The heart does not like major surgery anywhere near it. According to the literature, the heart will sometimes become irritated in 30% of thoracic surgery patients and convert from Normal sinus Rhythm (NSR) to A-Fib. Basically the heart decides to suddenly do the mambo and not pump blood so efficiently. Pain management and oxygenation are MAJOR issues with this patient because she's never NOT in pain. Epidural (pain medication that infuses directly into space around spine) has just been stopped. Nervous family watching my EVERY move. I learn to earn their trust by effectively managing her hemodynamic instability with fluid boluses and IV metoprolol. I learned that from my preceptor, Bill. He is not there today, but I remember hanging on his every word through the 10 weeks of orientation. I quietly think to myself, "I wish I still had a preceptor." Nope. Time to "nurse" up.
-Patient #3: 27 y.o. male p/w elevated troponins (heart muscle fibers) that indicate he's had a myocardial infarction (MI) 2/2 methamphetamine use. Pt. p/w CP and assaultive/aggresive behavior that requires restraints in the Emergency Department (ED). Pt. also in complete congestive heart failure (CHF) 2/2 profound substance abuse (SU). Pt. continues to be actively psychotic and later, we learn, has escaped from a lock-down psych facility after being brought in on 5150 hold for assaulting folks in the streets. Pt. complains of (c/0) dragons outside room. Pt. will eventually take off his cardiac monitor, insist we are sucking his soul away through the wires and inform me that despite the fact that I am good, that I am "dying" in my eyes. I must look tired. Good rapport established, he begins to trust me but will eventually rip out his own IV, shoot blood all over the floor, and begin sucking his own blood out. Before the day is through, he will also assault a secure officer with an ice-cream sandwich, try to escape multiple times, and require an amazing amount of anti-psychotic medication (seroquel, thorazine, ativan) before taking a nap. Because the patient trusts me, he takes medication by mouth (PO) but refuses another IV, which he also told me was sucking away his soul. I will have to monitor for extrapyramidal side effects (EPS--abnormal motor/neurological movement), neuroleptic malignant syndrome (NMS-sudden reaction/fever to some psych meds), and oversedation AND be extremely concerned about the condition of his heart. Pt. will eventually be restrained for assaulting another security guard. This time with his dinner tray.
-Patient #4. 56 yo male p/w increasing SOB and CP 2/2 CHF 2/2 genetic dilated cardiomyopathy (DCM). He will be initiated on a dobutamine drip that will keep his heart pumping until he can get a transplant. Dobutamine is calculated to the microgram and requires some serious attention when you've never managed before. I've only studied about it for the NCLEX and in my patho class with Pam ("let's get it started"), my favorite nurisng professor. I'm glad I studied so hard for the NCLEX. I'm even "gladder" I have time to read about how to administer this drug before giving it, monitor for side effects, and initiate proper hospital monitoring policy/protocol for this patient. This amounts to HELLA paperwork. Glad I arrived an hour early.
-Take report from night shift. Quietly wonder if this is manageable. Update resource nurse about my patients and who will be "heavy". I kind of think they're all heavy.
-Run my ASS off managing everything from hypochondrical family members to a patient crashing and almost needing to go to ICU. Frequent re-assessment for patients 1-4 because, well, they are not all that stable. Throw in a smattering of moody sleep-deprived residents and helpful residents. Everything is a blur and every monitor is beeping, calling my name for attention and assessment. My work cell-phone rings off the hook. I wash my hands at least 200 times. I try to be calm when 25% of my medications aren't available because pharmacy is backed up. I make friends with the pharmacist so that I can get things on-time for the rest of the day. I remind myself not to give patient #3 any more ice-cream sandwiches. I occasionally wonder how I am managing to not go insane as this actively psychotic patient. I call in support from veteran nurses but frequently realize that I need to act decisively and independently so as not to burden them from taking care of their own patients. Then the $35,000 medication comes and I need to administer it immediately. That's when Pt.#2 almost crashes. I am suddenly and inexplicably less overwhelmed right now because I know the crashing patient takes priority. I am now doing one thing and not a million things. I hand the $35,000 medication to the resource nurse and ask her, "Can you find out how to give this? I'll be right back (white lie), I need to call rapid response (team of nurses that respond to REALLY unstable patients)". Pt.#2 become stable after an hour of work. I am now REALLY behind. I become overwhelmed at one point because 2 pages of orders suddenly appeared in the chart that weren't there a minute ago. The orders were back-timed by a sneaky MD to read as if they were written @ 0800 and it is currently 1000 so I look like I neglected to execute important orders. Talk to resident about not doing that again. A different, helpful resident (R3 no less) gets excited about doing a Guiac Test on pt. #1 that now has been diagnosed with a upper gastrointestinal UGI bleed. I am happy to delegate a poop test to an excited doctor. I kind of love him for that. Now reader, I urge you, to never breathe deeply while handling melena (look it up and you will know it's definition: black, bloody, tarry poo. Smell it once and you will never be the same).
-At one point I will have to change my scrubs because, while helping a colleague, explosive diarrhea covers my scrubs, and I need to change. There's no washing this out. We call it a "code brown". After disgusting some folks on the elevator, and getting a new pair of scrubs from the basement, I take this opportunity to eat a power bar. After changing of course. And washing my hands for the 300th time. I get back to the patients and more of the same onslaught ensues. Constant reorganization and re-prioritization. Somehow it's all getting done. Thank GOD for the team. Blur. Blur. Triple Blur. I look up and it's almost time to go. I should probably chart more than vitals. Damn. I've got a half hour.
-Give report to newly refreshed night nurses. It is then that I remember that I didn't eat anything but the power bar or pee the whole day. After report, I then have the most satisfying pee of my whole life. It lasts an abnormally long time. I wonder if I've given myself prostitis or a UTI. Will find out next week.
-Leave hospital after tying up loose ends.
-Arrive @ car and assess whether I will fall asleep on way home. No.
-Arrive home and take a LONG shower.
-Wife now accepts kiss because she now is no longer concerned about poo/blood on me.
-Catch up with wife while eating Cheerios.
-Time to do it again.