Pushed to the Limit

Happy Belated Mother's Day to all the mom's out there.  I was supposed to work Sunday night, so I went to visit my mom on Saturday morning and bring her a few presents.  I worked Saturday night - it was a pretty good night with one exception...a patient that was ringing the call bell literally every 5 to 10 minutes.  When she wouldn't get a quick response, she'd take off her heart monitor because she knew someone would show up quickly to get it back on her.  She did that a few times as well as pulling out her IV.  At that point I decided it was time for some wrist restraints.  I went home that morning telling my clinical leader that I refuse to care for this patient again. 

To my surprise, I got a call from work at 5 pm Sunday night saying they were overstaffed & if I didn't want to come in, I didn't have to.  Yay!  I immediately got ready & headed over to my brother's house...where the rest of my family was so that I wouldn't have to hear my mom say "Remember the year that you missed Mother's Day?"  She had already said the day prior "You've never missed a Mother's Day."  I felt bad, but I told her the reason I scheduled myself that night was so that someone that actually was a mom could have the entire night off - it was their day, not mine.  She understood, but I know it made her day to have us all together for her holiday. 

I went into work Monday night only to see I had got the patient back that I had on Saturday night.  I wasn't happy, but by this time she had been in the hospital for about a week & pretty much every other nurse refused to care for her either.  She wasn't only bothersome, but she was also in a private room under "rule out TB" precautions...which meant having to put on a mask & gloves every time you were in the room.  Those masks can make your face pretty hot after only wearing them for a few minutes.  I don't like isolation rooms because of the extras we have to wear. 

She still had on her wrist restraints and I was told in report that she had what appeared to be "fake" seizures.  She had been sent for a CT of the brain to rule out a stroke and that was negative.  When I went in to assess her, she began to have what appeared to be a seizure...but it also looked like she was watching my reaction at the same time.  I looked at her & asked "Are you in pain?"  Because Saturday night she was continuously asking for pain medication and she had a history of IV drug abuse.  I wasn't even finished saying the word pain when she perked up & said "Yes, my back hurts.  I need pain medicine."  Hmmm...not the usual response when someone is having a seizure.  I questioned giving her any pain medication or anything to help her sleep because she was acting different than when I had her on Saturday.  She was more lethargic & not so demanding.  I figured I would play it by ear through the night as to whether to give her this medication or not.  She was brought into the hospital on the 5th because she developed chest pain while having dialysis.  I should also mention she was only in her late 40's.

My second patient that night was someone I have taken care of in the past.  She was also in her 40's and in with congestive heart failure.  She looked miserable & uncomfortable.  She has to sleep sitting up because it's the only way she can breathe.  That has to be uncomfortable night after night.

My third patient was a woman in her 70's that had a stroke.  She was having difficulty reading, writing & thinking of what to say.  Her speech was ok, but there was a delay in getting answers when I asked her questions.  She was very prim & proper...and a name dropper.  She mentioned to practically everyone she came into contact with that she was a neighbor of the CEO of the hospital.  I don't like name droppers.  She was not very happy as she was in the same room as my patient with congestive heart failure who happened to cough quite often.  My stroke patient thought the other patient was contagious and started to demand to have a private room.  Sometimes we can accomodate that, but not that night as the hospital was full.

My third patient was an elderly man in his 90's.  While I was getting report on him, I saw that he was wandering in the hall.  Hmmmm....he's not supposed to be.  He was asking "Can somebody help me get home?"  I walked him back to his room & called for another nurse to get me a posey vest.  This man had climbed out over the side rails!  I am sooooooooooo glad he didn't fall.  I didn't want to take any chances, so I put the vest on him to keep him in bed.  He was ok with it...at the time.

I got a fifth patient about an hour later - directly from the cath lab.  It was an outpatient procedure that had gone wrong & now he was being admitted.  The report I got was this "The patient had a AV graft for dialysis put in 5 days ago & it clotted.  So he came in today to dissolve the clot & they ended up with a perforation & couldn't stop the bleeding without extreme pressure.  They finally called in the surgeon who did what he had to do & the surgeon also spent about an hour applying pressure to stop the bleeding."  This was not sounding good to me at all.  I was told his blood pressure was ok, but his heart rate was in the 120's to 130's and he was in a lot of pain, but the pain medication was making him vomit.  Inside I was groaning about what a night this was going to be.

Two years ago I would have been scared completely as well as nervous.  It's amazing how relaxed one becomes after a little bit of experience.  Before my cath lab patient got to the floor, my confused elderly man was busy pulling off his heart monitor.  I tried to reorient him, tell him what he was in the hospital for, etc.  Shortly after that, my congestive heart failure patient started coughing so much that she was having difficulty breathing.  She was hunched over trying to catch her breath inbetween coughs.  The stroke lady was freaking out with all the coughing for fear that there were some contagious germs floating around the room.  She had pretty much barricaded herself behind the curtains that separate the two beds.

I called the doctor for the one coughing & got an order for Tessalon Perles - such a fancy name, isn't it?  It sounds like it should be a bath soap or something.  They do work...her coughing resolved rather quickly.  Yay!  Her roommate seemed content hiding behind the curtains. 

My confused man was still confused & not happy about being kept in bed.  He kept yelling out for help.  I called his doctor to get something to relax him.  I gave him Ativan which I silently prayed would do the trick...because you never know if it will help or if it will make things worse.  This time I lost...he got worse instead of better.  Oh well, at least he was safely restrained, right?

I got my cath lab patient.  He seemed pretty stable except for the pain.  I gave him Lortab as he didn't want the Morphine because it made him ill.  Lortabs aren't very strong & I didn't think it would really help all that much with the pain he was in.  He was a very patient man though & gave the Lortabs time to work.

I went to check on my isolation patient as I found it odd she was not using the call bell at all.  She was rather lethargic.  I thought maybe the lack of sleep had finally caught up with her.  She would wake up whenever I entered the room though, so it wasn't like she was out of it. 

I go to see my confused patient who is sharing a room with my cath lab patient.  The confused one has now taken off his heart monitor again as well as pulled out his IV.  Out come the wrist restraints - he wasn't happy.  I knew starting an IV on him would be next to impossible, so I asked if anyone wanted to volunteer to do it.  The patient was now becoming very agitated & rude.  He was calling us b*tches and wh*res.  Nice, huh?  Our cute pregnant nurse decided she'd take a chance.  She didn't last more than 30 seconds in there as he was yelling at her to kiss his ass.  I elected my clinical leader to do the job as she can be quite entertaining & if anyone can calm someone down, it's her.  As she was checking out his right arm for good veins, he attempted to kick her.  Ok, I don't play that game!  Out come the ankle restraints.  He had plenty of nasty things to say.  All I kept thinking was "The poor guy in the bed next to him who is in pain & just wants to sleep...yet has to put up with this disrespectful, confused individual."  We need all private rooms I tell you!  Luckily, the cath lab guy was very patient and I could hear him chuckling at times.  I thought "Hmmm, maybe this is helping to distract him from his pain."  The IV was put in & I once again prayed the Ativan would kick in at any minute now. 

Not more than 10 minutes later, I bring a pain pill to the one in pain and I see that the confused guy has his hands free & they are over his head.  Hmmm...how the heck did he do that???  He's a natural Houdini!  He was lying still & appeared to possibly be sleeping so I left him the way he was.  That was a mistake...it wasn't long before the heart monitor was off & the IV was pulled out again.  At this time, I told the patient care tech that we should probably change his sheets & his gown as he was incontinent & needed to be cleaned.  After that I'd simply put the wrist restraints back on & another IV in.  He cooperated for about 5 minutes, but then threatened to punch me.  I had been sweet prior to that threat...but I sternly told him that was no way to speak to me & he better not even try it.  He sat there looking at me....but it was a crazy enough look that I thought he might do it, so I called in the clinical leader again to diffuse the situation.  The three of us managed to clean him up, change his sheets & apply double wrist restraints all while the confused patient was threatening not only to sue us, but to also shoot us with his gun.  I don't care who you are....you aren't going to get the opportunity to punch me.  Another IV was started and we were out of there. 

It was about 1 am at this point and I hadn't even begun charting yet.  That's another 2 hours at least.  I manage to catch up and around 5 I hear my confused patient and my cath lab patient yelling at one another.  Uh oh.  The confused patient is yelling at the other guy to untie him.  The cath lab patient is yelling back that he deserves to be restrained, that he's rude & disrespectful and needs to learn how to treat people right.  This goes over well as the confused one begins swearing at the other one.  Ugh!  No one that is sick should have to put up with this!  The poor cath lab guy is in pain & just wants to sleep but is being kept awake & verbally assaulted by his roommate.  It didn't last long and when I went in to give the cath lab patient more pain medicine, he joked that he was now added to "the hit list."  I apologized to him that he had to put up with this.  He took it all in stride.

By now I could see the light at the end of the tunnel or so I thought.  It was about 6:30 when things went in another direction.  My isolation patient's heart rate went from 75 immediately up to 170 & then plummeted to 40 just like that.  Whoa!!!!!  Within a second she was back to her 75 beats per minute.  We checked on her & she was now pretty much non-responsive...I mean she would look at you if you said her name, but she wasn't talking...just moaning.  Not only that, but the rhythm she was now in...none of us knew what the heck it was.  There was no P waves to be found, but it wasn't a-flutter or a-fib either. 

I called the neurologist as it appeared that she had been having a seizure.  I described to him what was going on & he replies with "Well, what do you want me to do about it?"  Huh?????  You're the doctor, you tell me.  So he orders Ativan 1 mg & that's it.  I give her that & she's still not responding.  We got an EKG on her that was showing a new heart block.  My clinical leader who has been studying 12-lead EKG's recently was saying "it looks like she is starting to have a posterior MI (heart attack)."  Uh oh.....time to call the cardiologist only the cardiologist already signed off of her case like 8 days earlier.  So I call the primary doctor & luckily got the one that actually knows all about her.  I was dreading having to explain her entire history to someone on call.  He ordered for the cardiologist to be reconsulted.  That's it?  So I say "Dr., do you want the patient to be moved to ICU where she can be more closely observed or kept here in PCU?"  He said it was ok to transfer to ICU & the PCU day shift nurse coming onto duty was thrilled I got the transfer as this patient looked like she was going downhill fast.

I gave report to the ICU nurse who hadn't even been there 10 minutes and looked like she was ready to cry.  She already had a patient that died a few hours earlier, but the family was just coming in to see the body....about 30 family members.  And she had another patient that was going to be taken off of life support and that family was coming in also.  She knew it was going to be an emotional day. 

She ended up getting my patient around 8:15 am as I was on my way out the door to go home & get some sleep.  I found out later that my patient coded & died around 9:30.  Her daughter was there watching - hysterical - as could be expected.  I'd be the same way given the situation.  It was too much for this ICU nurse to handle.  I heard she was crying so much that they told her to finish charting & take the rest of the day off.  I feel for her, I feel for the families.  There is no easy way around something like this...emotionally or physically.

I had that guilty feeling after finding out she died - like did I miss something earlier?  Could the outcome have been different?  She did have a heart attack like my clinical leader picked up on, but at that point...the damage was already being done & there was no reversing it. 

I worked again last night and it was a pretty good night.  I had 5 patients again.  Two of the were the same (congestive heart failure patient and stroke patient).  Three were new to me.  I had asked not to have the confused mean guy back & wouldn't you know it...he barely said a word last night.  I have no idea what medications they gave him, but he did not cause one ounce of trouble.  I also didn't have the patient that was in pain - he had been transferred to ICU earlier that day as his heart rate went up to the 150's during dialysis and wasn't coming back down.  I was glad that at least now he had a private room without anyone yelling obscenities at him. 

I did have to call a doctor at 5 am this morning because of an elevated blood pressure.  I first paged him at 4:30 & got no response so the second time the answering service connected me to him directly.  He says "Hello?"  I explain to him who the patient is, why she's here & what the blood pressure is.  He asks what kind of cardiac meds is she on.  I tell him...then I hear......snoring!!!!!!!!  SNORING!!!!!!  I was wondering if it was him or if maybe his wife just snored loudly...lol.  I wait a few seconds hoping he'll say something & he does...he says "Hello?"  Ugh. So I say "hello" back to him.  He says "Ok, admit to tele & that's it."  What?????  She already is on the tele floor & how is "that's it" going to help her blood pressure?  So I say to him "Ummm, she is on PCU."  He replied "Then keep her there."  What??????  What else am I going to do with her??  Push her out the door?  He's ready to hang up & I say "Don't you want to do anything about this blood pressure?"  He asks me to repeat it again & finally gives me an order for Vasotec.  I looked it up in the drug reference to make sure it was ok for her to take...just in case since he obviously wasn't thinking with a clear mind.  It's scary getting orders sometimes.

I have the rest of the week off.  I'm going to take it easy today.  Tomorrow I think I'm going to go to Sarasota for the high school baseball finals.  My favorite team in in the final four and they just may win it all this year.  Go Bishop Moore!  If they do keep winning, I'll be in Sarasota until late Saturday night...then back to work on Sunday for just 2 nights.  After that I'm officially on vacation for over a month...woo hoo!!!  8 days to Hawaii - the countdown is on!!!