I worked 4 nights in a row this week. I was planning on doing 5 or 6 in a row, but my 4th night wore me out. I was due for a stressful night. I haven't really had one since the code blue back in the beginning of January. It seems like when it rains it pours. Either that or I simply don't really stress when I have one patient having problems...but when I have 3 out of 4 with serious problems....I start to stress.
Luckily I had one patient that remained stable, because I really didn't have much time to focus on her. She was in with pneumonia & I had been taking care of her for the last 3 nights. I was familiar enough with her to know that once she got her evening meds, she would most likely be fine throughout the night - other than when she requested pain medication.
The other 3 patients of mine were new admits. My first one came in with a diagnosis of congestive heart failure. He only spoke spanish. Why they didn't give him to a nurse that speaks spanish...I don't know, but he was mine. Everything was going along fine with him...I gave him his meds including a sleeping pill & pretty much expected him to have a nice night of sleep. About a 1/2 hour later, he sat up to use his urinal & his heart rate jumped up to the 180's. I brought my tech (she speaks spanish) in with me to tell him to lay down & luckily his heart rate went back down to his norm rather quickly. I had given him some blood pressure medications & Digoxin, so I figured once those kicked in, he'd be ok.
On to my next patient...this guy seems like he came from that tv show "House." He was a medical mystery, that's for sure. He also came in with chest pain. He was on the low-risk pathway. As I was reviewing his medical history, he tells me he's been in 3 head-on car accidents. He wasn't expected to live after the first one, but after something like 40 days in the hospital, he & his wife made it through. He also has a cerebral aneurysm that is inoperable. He has a history of seizures. He had a stroke about 15 yrs ago that put him into a coma for 3 months. He came out of it & was completely flaccid on his left side. A year later it resolved itself. On top of all that...he's been hit by lightning TWICE. I felt like I was talking to someone that should be in that movie "Final Destination." Talk about escaping fate time & time again! I get him settled in, review his orders & bring him his meds...he tells me he feels pain but he doesn't know where it's coming from. Huh?? He can't even describe the pain to me, it's just there. I'm picturing in my mind what a phone call to this patient's doctor would be like...."Umm, yes Dr., this patient is having some pain but he doesn't know where & he can't describe what it feels like." I put some oxygen on him & told him to breathe in through his nose. After a few minutes, he said the pain was gone. Ok, good. On to my next patient.
I get this woman in her late 60's from the ER. Again, she only speaks spanish. Why she wasn't assigned to one of the nurses on our floor that speaks spanish, I don't know...but she got me. Her daughter was with her & carried around a notebook full of all her mothers past medical tests. It was very organized, I was impressed. She got to the floor around 11:30 pm & was having trouble breathing, she was sweating, had a terrible headache...basically she was a mess. I got her a breathing treatment, her blood pressure was 177/90...so I gave her one of her blood pressure medications that the ER didn't bother to give her. Then I notice that while in the ER, she had a positive D-dimer (a test that can be an indicator of a pulmonary embolism). The ER did not follow up with a CT scan...like they are supposed to. So I call the doctor at midnight to get this test ordered. He didn't request it stat, so we put the order in & figured we'd have it done in the morning. The guy that works in CT scan called & said that it's usually done stat, but it's my call...what did I want to do. We decided to go ahead & have it done now rather than wait - just in case - but fully expecting it to be negative. So she goes down at 1 am for the CT scan. You think I'd be able to sit down & catch up on some paperwork.
Nope...my patient with the elevated heart rate earlier in the night....well, he's sound asleep but for some reason, his heart rate is sustaining 140 to 150. There is no cardiologist even consulted. So I call the admitting doctor who of course is not on call....I get one of his partners. This is one of the doctors that I really cannot stand. Anyways, he calls back....I tell him what's going on & he begins questioning me why there is no cardiologist on the case. I wanted to say "Ask your partner why he didn't order a consult for a cardiologist!!!!!!" He gives me a vague order for a cardizem bolus & if needed, a cardizem drip. Then tells me to find out who the patient would like for a cardiologist & put out a consult if necessary. The patient has no idea who his cardiologist is, so I go ahead & give the him the Cardizem bolus. It seemed to be working...ok, time to do some paperwork.
Yeah, right! My patient from CT scan is back & doesn't want to sleep. She's sitting up on the side of the bed. I was worried she'd fall off. I cannot get her to lay down back in bed & I cannot spend the rest of the shift babysitting her to make sure she doesn't fall. I take a chance & leave her be only to get back to my work area & find out she has not one pulmonary embolism....but two. Great! One in the left lung & one in the right. Ugh!!!!!!! I call the doctor again to update him - I'm sure they love these calls at 2 am. He's pretty much sound asleep & not saying much. Asks me to repeat what I just said to him. I swear, they need to come up with a better system than waking doctors up to give orders. He eventually wakes up enough to order Heparin & tells me to call the pulmonary doctor also. I call her even though she has yet to see the patient. She's not happy, but she's a little more alert enough to have me read through the orders & the medications...then tells me it's ok to start the Heparin.
At about the same time as this is going on, my patient on the Cardizem...well, his heart rate is back up to the 140's even though he's sound asleep. So it's time to hang the Cardizem drip. We get that going & I think he'll be fine through the rest of the night.
I get the Heparin for the patient with the pulmonary embolism's & have the nurse that speaks spanish explain to the patient what is going on & how important it is for her to remain in bed. We set up the Heparin & the patient is now refusing to lie down. She wants to sit up...it's easier for her to breathe. The last time I had a patient who was requesting to sit up to breathe...she coded & died. I was worried this might end up being the same situation. I finally get her to lay down, Heparin is running....ok, now I can sit down & do some paperwork.
Nope, my patient on the Cardizem in a matter of 2 hours now has a heart rate in the 60's. Then for a few seconds, it drops down to 45. Time to turn off the Cardizem. He remains anywhere from 45 to 75, going back & forth.
I go in to check on my patient on Heparin. She's now sitting up on the edge of the bed (grrrr) & complaining of chest pain. She's speaking in Spanish...I don't understand a word, so I get the other nurse. She is saying it isn't chest pain so much as all the coughing is making her muscles ache. She's also having trouble breathing. I call respiratory for a breathing treatment & give her some pain medication & continue to observe her.
My patient that was struck by lightning twice...well, now his heart rate went from the 70's to the 40's...only the rhythm isn't normal. I assessed him, he was asymptomatic & his heart rate goes up to the high 50's...I can deal with that since he is in sleep mode.
Now it's time to get some paperwork done quickly. I do not like staying past my shift...even on crazy nights. As I'm attempting to get this done, now I have the doctor calling me about the Heparin...not one call, but two. I managed to get all the paperwork done. Gina helped me out with going over the orders to make sure everything was entered for the new admits. That helped a lot. Trust me, I was counting down the time for the end of my shift.
I go in to check on my Heparin patient...she's finally laying down & sleeping. Everyone seems to be stable....time to give report. As I was giving report on her, Gina tells me this patient is complaining of pain. Luckily the doctor showed up & went to assess her. I could not wait to clock out!!! :)
I had been planning to work Friday night, but after a stressful night...I knew I needed some R&R. Last night I went to watch my nephew Eric play baseball. As it turns out, at the end of the first inning, his team was winning 12-0...so they took him & the other good players on his team out of the game so some other guys could play. Oh well, it was a beautiful night & it was nice to be anywhere but at the hospital.
Have a good weekend!