Tuesday, January 23, 2007

Dancing Doctors & stuff

I've only worked 2 nights this week so far & I'm already feeling overwhelmed. I started out Sunday night feeling like I was in a fog. I felt so behind in my charting, yet can't really figure out why. The time just flew by.

When I got to work, one of my patients that I was assigned to had orders to be immediately transferred to ICU because technically she was an ICU patient. What was she doing on PCU? They didn't have enough ICU nurses during the day, so they sent her to us. Doesn't make sense...she should have stayed in the ER until there was an ICU nurse available. She was in the midst of having a heart attack (Troponin level on the second set was 20, normal is less than 0.4) & come to find out, she nearly coded yesterday in the ICU. I'm thanking my lucky stars that I didn't have her as a patient. Since I hadn't taken report yet, I had the day nurse give report directly to the ICU nurse & I assisted in moving her over there.

So now I was down to three patients. My first one was an older woman in with a TIA...transient ischemic attack....often referred to as a mini-stroke. She had no deficits, was feeling fine, but they were keeping her because her INR level was 1.4. Normal is between 2 & 3. She was pretty simple to care for.

My next patient was a woman in her mid-40's with a diagnosis of "frequent falls." I didn't realize that was a medical diagnosis, but anyways...she was falling down more than usual. She wasn't dizzy nor did she feel weak, but she'd still fall without any control over it. She has a history of breast cancer & the neuro doctor was concerned that the cancer may have returned. So he ordered a stat MRI of her spine & sure enough...the cancer has moved to her spine & the tumors growing are causing spinal cord compression. We immediately consulted the oncology doctor that does radiation. I spoke with him on the phone that night & he told me to inform the patient he would be coming in to see her between 6 & 7 am the next morning. I told him that she doesn't know the results of the test & he said he would break the news to her in the morning. I hate, hate, hate having terrible information that the patient doesn't know about their condition. I do my part that's expected of me & not divulge anything - that's the doctor's responsibility, but that doesn't make it any easier. I saw him in there the following morning talking to her & I went in after he left the room & she was crying...which I totally expected. She then says to me "Did you know about this all along? Did you know the entire night?" Ughhhhhhhh, I don't want to lie, but I also don't think she'd logically understand that nurses cannot give patients that type of devastating information - it's the doctors that handle that. I told her I didn't know all the details & she accepted that. She continued to cry. I didn't know what to really say to her. Cancer scares me, no one knows whether they will beat it or not & with it having already spread to the spine, chances are it's in other places too. They were running other tests, the results will probably be back today.

My third patient is one that has been at the hospital for over 3 weeks now. It started out with low electrolytes & nausea/vomiting. Now...I'm not sure what all is going on with her, but she looks miserable. She's in her early 40's but is developmentally delayed...has the mind of a 6 yr old. She was scheduled for a laparascopic lysis of adhesions from a prior surgery. When I assessed her, I saw that she has IV fluids running at 150 cc/hr as well as TPN & lipids.....so she was getting nearly 100 cc/hr combining those two....so roughly 250 cc/hr if you combine her IV fluids with the TPN & lipids. She had so much edema, she looked like she could pop. It was everywhere. She was third spacing big time. I couldn't understand why they were giving her so much fluid when it seemed like with the edema, it was too much for her body to handle. She was stable thankfully.

I got my fourth patient sometime during the night. A gentleman that came in because he felt like he was having a stroke. He didn't have any deficits other than feeling like his legs were weak or his speech was slurred....neither was really happening. I saw him walking around the room, his legs seemed very strong and his speech sounded very clear to me. I continued to observe him every 2 hours with neuro checks. I'm sure he was annoyed with me by the end of the shift. Nothing like waking someone up every 2 hours to ask the same questions & do the same assessment over & over.

That was my Sunday night...nothing major, just busy work. Monday night I got the same patients back. One was down for a CT scan, the other was in surgery. So I quickly assessed my remaining 2 patients & charted on them. I got my 3rd patient back...the one with cancer of the spine. The doctor that morning wanted to start radiation on her immediately...so fast that she was already having it started by 7:30 am. I went in to assess her Monday night & she was continuing to cry, followed by moments of something totally different. They have a consult ordered with the psych doctor for a history of bipolar disorder. She slept pretty much the entire night. I was thinking the radiation wore her out possibly. I was battling with her blood sugar though.

When she came back from CT scan, she wanted food. I had been told her accucheck before going for the test had been 470. So I told her I wanted to check it before I gave her anything to eat. It was 527. So I put a call out to the doctor...who of course wasn't on call & I got one of his partners....one that is not much fun to talk to. He started rattling off orders for insulin & I told him that she is on sliding scale protocol & that I already gave her 15 units of Regular insulin sub-q. I also informed him that she was on Decadron (causes your blood sugar to skyrocket). So he tells me to hold the Decadron & then says "I don't know this patient, I don't know what you want from me." Ummm....some orders on how to treat this outrageously high blood sugar. So he tells me to hold the Decadron & clarify in the morning what the doctors want to do with it & to recheck her blood sugar in 2 hours. Ok, no problem, that's all I needed to hear. So I recheck in 2 hours, it's 472. That's a better number, but still high for my comfort. So I call the on call doctor again. I'm sure he was thrilled to hear from me. He ordered 5 units Regular insulin IV & recheck in 2 hours. So I do...now it's 465. Another call to his answering service - seems now he is requesting to be called directly at home - skip the answering service paging him. So I do just that & he says "Heyyy, it's coming down." From 472 to 465 & he's happy? So he orders the IV insulin again & recheck in 2 hours. This time it was 285. I can live with that...I'm not happy, but it beats the 400 to 500 range.

While I was dealing with that, my surgical patient returned to the floor...in a great deal of pain & plenty of confusion about the orders for me. Nice combination! I was told by PACU that she lost blood during the operation & that she was given 2 units of red blood cells in PACU & that I was to give her a third unit. They leave & I assess my patient only to see blood coming through her gown...lovely. I knew they had switched the surgery from laparascopic to having to open her up. So she had an incision on her abdomen..stapled together...without any dressing. There was a small amount of blood coming out. Of course now I'm worried that she has some internal bleeding going on. I give her a little bit of pain medication...just a little bit because her blood pressure was 92/53. Didn't want the pain medication to drop her further. I look over the doctor's orders & see no order for blood. Hmmm, that's not good. So I call the surgeon to clarify whether she needs blood or not & he tells me he never agreed with that order, that she didn't lose any blood during surgery & he thought the lab results were wrong. Hmmm..that wouldn't be the first time a surgeon claimed something different went on in the OR than what everyone else is saying. So he tells me to recheck the Hemoglobin & Hematocrit & gives parameters as far as whether she needs another unit of blood. Then silly me throws at him that her blood sugar is only 71 & she is NPO (nothing to eat or drink). He replies "Isn't she on D5 1/2 normal saline?" Oops...yep, just got it started after she returned from PACU. I rechecked it & she was up to 92, which is good.

A little while later, my tech is telling me that her blood pressure is now 73/62. Are you sure? Rechecked it in both arms. So I do a manual BP....sure enough, she's 70/60...NOT GOOD. And her heart rate is in the mid 140's...NOT GOOD. I call the surgeon again to report my latest findings & he's ordering a 1500 cc bolus. Ummm, you do know she has pitting edema & is third spacing, don't you? He told me he knows, but she obviously needs fluids to drive up that BP. This is where I am confused & would love for someone to explain to me....wouldn't more fluids just cause more edema? And why is she third spacing if she is dry? Why aren't they giving her anything to get rid of that edema?

So as he's giving orders on how to treat the patient, I throw in there "Would you like her to remain on PCU or transfer to ICU?" He opted for a transfer to ICU. I don't think he would have done that had I not spoke up, but she was just too much to handle for me. I kept an eye on her vitals while she was in ICU...they were a little better, but not much. She definitely belongs in ICU right now. I have no problem admitting I'm not ready for someone that is in the condition she is. And as it turns out, the surgeon was right - she didn't need any more blood. Her hemoglobin was 13.3. The earlier one stating 7.7 was obviously wrong & he was right. I was impressed because usually we see where doctors mess up - it was nice to see where this one had it right all along.

My gentleman with the stroke...turns out he also has cancer that metastized...to his brain. Ugh, not good news. His mood was good though - I think he was just hiding the stress from me. I wish I had the right words to say when someone receives news like that...but there probably are no right words.

I'm going back for more tonight. Hopefully my night won't be so chaotic. :)

Oh, almost forgot...the title of this blog entry. Monday morning around 6 am, one of the doctors was inearly & not sitting too far away from me. I had my mp3 player playing some dance music. Next thing I know, he's all curious about it...because my phone is my mp3 player also. He starts singing...not very good, but it was cracking me up. He's asking me questions, then goes back to charting & comes back & asks "Do you have my song?" I asked what song is that & he replied "Sexy back." Yep, of course I have that song, so I turn it on & he asks me to turn it up & he starts singing & dancing around the nurses station. I was cracking up. Some of these docs can be amusing at times.


molly146012 said...

WOW! you have been soooooooooo busy....I love how you explain everything in your entries so easy to read and so interesting. ...makes you feel like you're right there! LOVE your blog. :) feel sorry for the patient with spine cancer ....so young.
hope you get some rest...and have a nice day...Molly

tendernoggle said...

So sad about the cancer patients...I now that puts a lt of stress on you...so I was happy to hear that the doctor sort of released some of it for you! lol You should write a book!
love ya,

am4039 said...

I'm so sorry about the patients. The lady that had the cancer come back how very sad. You have a rough job.