Monday, October 20, 2008

D50 Recordsetting shift

I finally managed to get myself on a day schedule (sleepwise) - yay! Somehow I believed that this would make me more productive on my days off. Nope, not true. I was supposed to go thru my closets this weekend and get rid of clothes and things I no longer need. What do I have to show for this effort = some clothing I managed to iron and hang up but has not yet reached my closet, some clothing I ironed but still in need of hangers and plenty of clothing that still needs to be ironed and oh.....one shirt to give away. ONE SHIRT! Something is better than nothing, right?

Work has kept me busy. I had decided to move to the 3rd floor PCU permanently - but about 2 or 3 shifts into that decision, I was feeling like it was the wrong decision. I'm just out of my comfort zone up there. They say PCU is PCU...but not true. Our 60 or so PCU beds are split between the 2nd and 3rd floors. I have worked 95% of the last 3 1/2 years on the 2nd floor. There are things I like and dislike about both floors. I did email the manager or director - whatever she is and requested to go back to my comfort zone on the 2nd floor. I never got a response. Hmmm. So now the last 2 weeks I have been floating back and forth between the two floors. I'm feeling like I have no home...lol. I did find out that we are probably going to be opening up an observation unit in January and I did tell them I was "somewhat" interested in "possibly" working there. (am I a commitment phobe or what??) We'll see what happens.

I did set a new record for myself and probably or should I say hopefully no one else can match it. I had a patient that came in with renal failure. When my shift started, his blood sugar was 64......and he had already had D10 running at 50 ml/hr and already had dinner. I wasn't messing around. I gave him a 1/2 amp of D50...fully anticipating that this would keep his blood sugar in a decent range for the rest of the night. Nope, not happening. I recheck it about 30 min later and he is in the 80's, but it should be much higher after what I gave him as well as having D50 running. About 30 min later, the patient tells me he feels like his sugar is low & this is after watching him eat a candy bar within that 30 min period. So I recheck and sure enough he's something like 54. Gasp! So I give him the other 1/2 amp & recheck 30 min later...he's back in the 80's. I'm not so confident that this is going to keep him ok overnight. So I call the doctor to report what I am dealing with. He says that's fine - just keep following the protocol.

30 min goes by, the patient again says he's not feeling right - recheck = 56. Grrrrrrr....this isn't good. Another 1/2 amp as well as a turkey sandwich, milk, juice...whatever he could possibly bear to eat or drink. Inbetween all of this, he's asking me why his blood sugar is so low. I asked him what medications he had taken prior to coming into the hospital & he says "I don't know." I told him I tend to think that low blood sugar for diabetics is usually medication related & that it could be awhile before his blood sugars stabilize. We go through another round of rechecks and it's still not over 70. He is sick of eating & drinking....so I give yet another 1/2 amp of D50. Recheck shows his blood sugar is even lower than before I gave the 1/2 amp. It's midnight now and I decide to call the doctor again - mostly because I have never in my life given more than 1 amp of D50 to a patient with low blood sugar & I am not confident this is what we should keep doing as it's obviously not working.

So I call the doctor - luckily he is one of the nice doctors who doesn't get upset with phone calls. I explain to him the situation. He tells me to give a full amp of D50 and also 1 mg of Glucagon IM and increase the D10 IV to 75 ml/hr. Ummm....ok....since he says so. Then he follows it up with "You don't need to keep calling me, just follow the protocol." Uhhhh....ok, just wanted to be sure you were informed as I have never had to repeatedly keep giving D50. His blood sugar should have been over 500 with as much as I had already given him.

So I give the full amp, give the Glucagon, turn up the IV...recheck 30 min later and it's 108. That's a little better, but seriously...it should have been in the 600's at least with all that medication. Tick tock....30 min later and he's complaining about not feeling well again. He's back in the 50's. How is this possible??? It was a cycle of that the entire shift. Luckily I only had 3 patients that night and the other 2 were sleeping with no problems. Looking back, I should have asked the doctor to upgrade this patient to ICU status as we don't tend to have the time because of our usual patient load (4 to 5 patients) to be doing accuchecks every 1/2 hour. However, I found it intriguing....so I kept at it!

I felt bad for the patient. He never really got any sleep because I was constantly in there assessing him. Finally it's about 6 am & I feel the doctor really needs to be updated as the protocol wasn't working and I was worried. I had given in 12 hours.....4 full amps of D50 IV as well as the one time dose of Glucagon and the patient had D10 running at 75 ml/hr....and his blood sugar at 6 am = 53. I hadn't called the doctor in 6 hours, he should be happy I left him alone for that long. So I update the doctor and inform him that I have never ever given this much D50. He can hear the worry in my voice and says to me "What's the alternative?" True...no D50 = the patient dies. Still though - he was in for renal failure and I know D50 is rough on the kidneys. The doctor assures me that we have no other alternative. I ask if he wants to increase the D10. His reply..."I don't want to put the patient into renal failure." Ummmm....doc....that's what he came in with.

So he agrees to up the rate as well as continue to follow the protocol. He tells me there is a slight chance the patient could have an insulin producing tumor in his body. I was doubtful...I mean what are the chances that he would be in the hospital on the very night this tumor decided to start producing insulin? Not likely.

I gave report to the dayshift nurse only to come back that night and find they transferred him to ICU. He needed closer monitoring. I found out he was discharged a few days later - so chances are it was medication related and not a tumor.

Sooooooooo....on another note.....I haven't been back to the other hospital in over a month, I think. I don't like the team nursing concept at all. The last time I was there, I felt like my fellow team nurse (let's call her "nosy") interferred in my patient care & I didn't like it one bit. Nosy knew nothing about my patient, yet felt it necessary to make a scene in the nurses station, proceeded to call the doctor (even though the primary doctor had just been there & assessed the patient) and when he began asking her questions, she panicked & handed the phone to me & ran out of the nurses station. I didn't think the doctor even needed to be called in the first place & I told him that. Nosy was ready to call a rapid response. My patient was a DNR....do we call rapid responses on DNR's? I had never been faced with that dilemma before - not that I felt my patient even needed a rapid response. He ended up being discharged the next day with hospice. He was a 94 yr old with congestive heart failure, aspiration pneumonia and c-diff....he wasn't going to get better. His body was tired out and filled with fluid. We can't save them all.

I don't like being forced to work with nosy....ooops, I mean that closely with someone that is virtually a stranger to me. She ended up leaving at 11 pm and the next nurse that came on...my "new partner"....I walked up to her and tried to be cordial & said "I guess we're partners." She basically thru her hands up in the air & said "Whatever" & walked off. Ok, just the way I prefer it - you do your thing, I'll do mine. If I need help...I'll seek out another nurse or the charge nurse...not a "partner."

I'll go back there sometime this next month, but the majority of my shifts will be at my usual hospital. I am still contemplating travel nursing, but my youngest niece begs me to not leave her - so I'm sticking around for now.

On a not so great note...I got a speeding ticket today. Actually I should say...again. It was the same darn cop as last time! I opted for driving school with the last one, so this time I'm gonna have to take the points...grrrr. $181 out the door. Oh well, my bad. So much for having a RN magnet on the back of my car.

I figured I'd end this post with a few things that not many...heck...absolutely no one knows about me....

1) I love half-frozen bottles of coke. It's messy when I first open the bottle, but that icy cold coca-cola can't be beat.

2) I'd say 90% of my scrub tops have hearts on them. I'm not even a heart-type of a person....if that makes sense! Why in the world do I have so many scrub tops with hearts????????

3) I could watch Travis Barker play the drums for hours. Don't ask me why...I don't know....I go into a trance watching him play the drums. It's not even that I like him...not that I dislike him either.....but there's something stress relieving and soothing about him playing drums. I have a video of him on my myspace page...check it out so you can see what I'm talking about.

Ok, that's enough for now! Have a good week everyone!!!!!!

3 comments:

Carlene Noggle said...

I KNOW THAT HAD TO BE A LOT OF STRESS ON YOU TO HAVE TO KEEP GIVING THAT POOR PATIENT ALL THOSE MEDS...SEEMS LIKE THE NURSES DO THE MAJORITY OF THE WORK, HUH?
LOVE YA,
CARLENE

Amanda said...

That is OUTRAGEOUS!! I can not believe that the doctor was so chill about it. And honestly, if you had just been following protocool, you wouldn't be checking him so often, so her REALLY needed an upgrade to ICU status. we don't have "team" nursing, thank goodness. I have a few nosy co-workers and I hate whne they decide to "Help" me out by going in my rooms and doing things.

Life as a Paramedic said...

WOW!!!

The most I have given to one patient in the field is 2 amp of D50 and a mg of Glucagon. But that is crazy how you had to do that. I give you kudos.

First time here at your blog and I LOVE your entries. I will definately be back.