THE FINAL STRAW

One more day to go...I do believe that Monday night will be my final night working for the second hospital.  I am planning to give my 2-weeks notice after my shift is over that night & since I am not scheduled to work for 3 weeks, I believe it will be my final shift there.  The reason = incompetent staff.  I truly believe my nursing license is at stake if I remain working in such an unsafe environment.  Maybe I'm overreacting because I'm new or because I have different expectations of patient care...but I rather err on the side of caution than what I experienced during my shift last night:

When I arrived for my shift last night, I saw that I did not receive all of the patients I had the night before.  Instead, they gave me a new admit & gave one of my patients to someone else.  When I questioned this, I was told "Well, that nurse is also going to be the charge nurse tonight, so she can't take the new patient - he has too many issues going on."  Nice answer, huh?  Let's give the new nurse the toughest patient on the floor.  I looked at the telemonitor & saw that this patient's heart rate was 150.  I asked the day charge nurse "Is this being addressed?  Has he been given any meds to bring down his heart rate?"  She looked at me like I was overreacting.  She said a call was placed to the primary doctor (he had no consults) & that I shouldn't be so concerned about the heart rate.  HUH??????  Not concerned about a patient that is sustaining a heart rate of 150?  She advised me to get report from the dayshift nurse & I would understand why his heart rate was so high.  Ummm, ok.  Not the answer I wanted, but figured I'd see what's up. 

The day nurse advises me that this patient is a "frequent flyer" (shows up at the hospital often).  And that he is not only yelling & screaming at her, but he's urinating & deficating all over the floor multiple times.  Wonderful!  Add on that he has tuberculosis & aids as well as a heart rate of 150 for the last 3 to 5 hours...can it get much better?  Oh yeah...his H&H is 7.1/24.0 and his K+ is 2.8.  NONE of which has been addressed neither in the ER or when he got to the floor.  If this had been my first hospital - he would not have even been admitted to PCU, much less a surgical telemetry floor = he would have gone directly to ICU.  However, we are not talking about my first hospital...this is the second hospital.  I leave report & the day charge nurse tells me "The doctor called, I got you Ativan 1 mg & to transfuse 2 units of red blood cells & if pt's heart rate remains greater than 120 after the 2 units have been transfused, to consult a cardiologist."  What kind of orders are those?????  I'm not a doctor, but I had a pretty darn good feeling that this pt's problems would not be resolved with 1 mg of Ativan.   And I'm supposed to watch this patient's heart rate remain elevated for at least the next 4 to 8 hours & hope that the Ativan & blood brings it down?  I'm not a cardiologist, but in my limited experience, this patient would need a cardiac med to slow down the heart rate.  When I questioned it again with the day charge nurse, she replied again with a comment such as not to be so concerned about the heart rate, that the patient has issues.  Issues!

I go in to assess this patient with issues - totally expecting some out of control madman.  What I find is my patient lying in bed practically sleeping although he is awake.  I went ahead & gave the Ativan in hopes that his heart rate would come down a little.  I quickly checked on my other 4 patients to make sure they were stable, then I went back to this patient.  I wanted to get the blood transfusion started as soon as possible.  He had been typed & crossmatched before I arrived, but no blood consent form was signed - I found that odd, but went ahead & got him to sign it.  The ativan had practically knocked him out, but his heart rate was actually increasing.  It was in the 160's now!  I turned to the night charge nurse for advice - she had none.  She wasn't concerned one single bit about this patient or his condition.  She had patients of her own & that is all she wanted to focus on.  Her advice to me - give the pt some Tylenol.  TYLENOL????  He did have an temp of 101.3, so I gave him 625 mg of Tylenol & called the nursing supervisor.  I informed him of the dr's order to consult a cardiologist after the blood was transfused if the heart rate remained above 120.  I told the supervisor I was not comfortable with sitting here watching this patient tach away with a rate of 160-165 & not be doing anything to get that rate down.  He agreed & advised me to call the doctor.  Again though, the supervisor was not really concerned overall.  I called the doctor & basically told him that we needed to address this patient's heart rate as well as I needed an order from him to start the blood transfusion even though the patient had an elevated temp.  I rec'd an order to push Cardizem 10 mg IV & go ahead with the transfusion....and give Xanax 0.25 mg.  Why Xanax?  The patient couldn't be any more still in bed than he already was, but I went ahead & gave it as well as the Cardizem.  Gina was kind enough to go down & pick up the unit of blood....finally got that started at midnight.  I continue to watch the monitor & the heart rate has not changed at all = 160.  Ughhhhhh!  An hour goes by, still no change.  I call another nursing supervisor to inform her of this, she tells me to call the doctor again.  She is not overall concerned either.  Why am I the only one worried about this patient that has now gone nearly 7 hours (that I know of) with a heart rate higher than 150?  I call & wake the doctor, receive an order for 5 mg more of Cardizem and 0.5 mg of Digoxin.  I administer it & hoping it works.  Luckily after another couple of hours, his heart rate is down to 125-130.  By the time I left this morning, it was 115 - yay!  I found out a couple of hours later, he signed out AMA.  I get the feeling that no one at that hospital probably even cared or urged him to stay. 

It just amazes me the attitude at that hospital.  I know he was a lot of work, a pain in the neck & non-compliant outside of the hospital.....but aren't we supposed to give them the best care we can while they are in the hospital?  Maybe I'm still naive, not yet jaded....maybe I'm too worried about keeping my nursing license or don't know the ins & outs of covering my butt so I do things by the book...I don't know.   However, their lack of concern really opened my eyes to the danger I am placing myself in by remaining on a unit such as that one.  I have no support staff, no one to turn to when things are going bad......except Gina, who is another first-year nurse like me.  I can't imagine what takes place there when someone codes or has a heart attack.  The phrase "Give him some tylenol" plays in my mind.  As if Tylenol is some miracle cure.

Somehow Gina is more fed up with how things were last night than I was.  We both called off for tonight.  I don't want to go back, but I am scheduled for one more shift on Monday night & will fulfill my obligation as well as give a letter of resignation/two week notice.  When I called in today, my unit manager responded with "Your troubled patient signed himself out AMA if that makes a difference."  As if it was the patient that is causing these doubts I have.  It's not the patient's fault that his heart rate was tachy & no one at the hospital wanted to address it. 

Sooooo, luckily my first hospital is very short-handed & picking up extra shifts will be no problem.  At the same time, I have managed to save up some money & I may take a couple of weeks off in November or December.  I'll just play it by ear.  I am looking more & more into travel nursing.  I'd like to start out somewhere local through the holidays & perhaps actually travel elsewhere in the state or even out of state in 2006.  That's my latest plan anyways. 

I did have a situation arise on Monday night while at work.  One of my patient's was the father-in-law of one of the nursing supervisors.  Upon his return from surgery, the father-in-law told the supervisor to get out of his room, that they were not family.  So rather than asking his father-in-law how he was doing, the supervisor would ask me.  Anyone in nursing knows all about HIPPA...which is basically the patient's right to privacy.  I didn't like the situation this supervisor was putting me in - the patient obviously didn't want him to know anything & yet he was asking.  What do you do?  I managed to avoid the supervisor all of Monday night...lol...so I didn't violate any privacy issues.  By Tuesday it seemed the anesthesia had worn off of my patient & he was a little more receptive to his son-in-law being involved in his care. 

Anyways, that is the latest saga of my nursing adventures.  I am still tired & worn out from last night.  My feet are killing me, I have a headache...but at least I finally have an answer.  I have learned a valuable lesson.  If something sounds too good to be true, it usually is.  Computerized charting, admission nurses & patient care techs are wonderful to have, but it doesn't mean squat if you are working in a unit that throws you to the wolves.  That short chapter of my life is closing...by choice.

Oh, one more thing....Hurricane Wilma...make her go away!  More updates to come.