Reporting for Duty

Nurses give report twice a day, every day.  The day shift gives report to the night shift; the night shift gives report to the day shift.  Report is the time when very important information is passed from one nurse to another. 

Information like:

*What drips are running and how they are being titrated

*Lab values, trends and when the next labs are due

*Whether we are wedging the Swan-Ganz catheter threaded into the patient's heart, or whether the physician thinks there is too big a risk of pulmonary artery rupture

*EKG's, upcoming tests and procedures


This information is being relayed by a nurse who is exhausted; they have halitosis and their hair looks like it was combed with an eggbeater. They're trying to keep their speech clear and comprehensible so they don't end up in the CT scanner.

Interrupting report is dangerous. Things get missed; errors increase. Distractions should be minimized. This includes family members walking up to ask for soda, a washcloth or to have their parking pass stamped.


If you work at McDonald's and you make a mistake, someone might get a hamburger rather than a cheeseburger.  If you work in a hospital and you make a mistake, someone could die.  The stress level is titanic.

 

I've Got the Floor

Floor nurses have the largest nurse-to-patient ratio of any area of the hospital.  Depending on the hospital, floor nurses can have four, five, six, seven or even eight patients. 

When I first became a nurse, I started on a 22 bed unit, and at night I split it with another nurse. 

That was not a typo.  Me and one other nurse split a 22 bed unit. 

Things like giving baths, helping with meals, explaining medications, treatments and goals of care were like dreams from another reality.  We ran in the patient's room, did the most cursory of assessments, threw their meds at them and ran out.  A patient who wasn't on the call light and had no frequent medications usually didn't get seen more than once.  Medical students, family members and respiratory therapists found patients cold and dead in their beds in those days.

It was all paper charting back then.  The night shift had to do the 24 hour chart checks, the MAR reconciliations, put in all our own orders and start the next day's flow sheets.  Just managing that avalanche of paperwork alone was a full time job.

In theory, floor patients are supposed to be very stable.  But they can also be very sick and getting chemotherapy, blood transfusions, heparin or insulin drips. 

Floor nursing is like  rehearsing Shakespeare in a mall parking lot.  The constant chaos and distractions makes progress difficult.

Tele Vision

Tele nurses have challenges.  A typical patient assignment on a tele floor is four patients to one nurse.  That's more patients than on an ICU but less than on a med/surg floor.  If one patient becomes needy and dominates the nurse's time, the other three can be neglected. 

Some tele patients are walking around sipping cranberry juice and telling inappropriate jokes.  But some are fresh out of the ICU.  The "tipping point" on these patients can be razor-thin.  Tele floors take patients with intravenous drips like heparin, nitroglycerin, lasix, insulin, dopamine, dobutamine, milrinone, cardizem and cardene and all the labs and vital signs that come with them. 

Working on a tele floor is like teaching four caffeinated ADHD guys to use power tools.

I See You Nurses

ICU nurses frequently suffer from a slightly different version of Being Fabulous than ED nurses.

Many ICU nurses have never worked even one day on the floor, so they don't understand a floor nurse's job.   It's easy for ICU nurses to develop a superior attitude and not realize that one kind of nursing is not better or worse than another, they're just different.  Like apples and kumquats. 

ICU nursing is like trying to organize, prepare and serve an endless course dinner to two gourmets at a four-star restaurant.  You  may only have two customers, but they're so discerning there's no room for error.

EMERGENCY!!! EMERGENCY!!!

Nurses in the Emergency Department get a lot of publicity.  More movies and television shows are set in the ED than all the other areas of the hospital combined.  When was the last time you saw a television show set in a dialysis clinic?

88% of ED patients walk out the front door. 

I'm gonna say that again:   88% WALK OUT THE FRONT DOOR. 

What that means is that patients on the quietest med/surg floor are still sicker than most ED patients.

I've worked some in the ED.  I got to see a lot of vaginal discharge, nauseous kids, drunk prostitutes, whiny men with back aches and drug seekers.  There were some broken arms set and fluids given, but mostly I saw folks patted on their fuzzy heads and sent home.

The ED is like a big wall of graffiti.  The majority of it is just crap.  But mixed in are a few things you better not miss.

Nurse's Note:  If a patient comes in to the ED with a heart attack, a nurse from the Cardiac ICU responds. If a trauma patient comes in, a nurse from the Surgical ICU responds. If a patient is brought in with a stroke, a nurse from the Neuro ICU responds. If a burned patient comes in, a nurse from the Burn ICU responds. I have never seen any of those nurse responders portrayed on television. The televison ED nurse somehow specializes in every diagnoses.

The Sugar Diabetes

Some of my older patients tell me they have, "The sugar diabetes".  This always confuses me...is there another kind of diabetes?*  

Diabetes seems benign.  The patient feels pretty normal, so it's easy to ignore.  But consider a diagnosis of diabetes comparable to a diagnosis of cancer.  It's an illness that should be taken VERY seriously. 

If you have diabetes and you aren't controlling your blood sugars religiously, YOU'RE JUST NOT SCARED ENOUGH.

In the USA, diabetes is the #1 cause of blindness, kidney failure and amputation.  Diabetics are two and a half times more likely to have a stroke, and 75% of diabetics die of heart attacks.   

Nurse's Note: I'd take HIV over diabetes.

*Another Nurse's Note:  I am aware of diabetes insipidus and gestational diabetes.  

Anhedonia Sports

Once upon a time, there was a state called, "Anhedonia".  Anhedonia is nearly a perfect geometrical shape--let's say a circle.  The Gusto River cuts into the northeast corner of the state (a cerebral fracture) preventing it from being a perfect circle.

Anhedonia has two state universities:  one in the city of Ecstasy and one in the city of Malady.  These two noble institutes of higher learning both have several gladiator-type sports to bring in lots of money. 

Each university has a mascot:

 

 

Ecstasy has a Purple Kitty

 

 

And Malady has a Criminal Chicken 

 (see earlier blogpost, "Blackmailers VS Child Molesters)

The good people of Anhedonia have a lots of fun arguing about who will win the Pastabowl this year and the Toiletbowl next year--the Purple Kitties or the Criminal Chickens?  People get drunk, cars are turned over, fistfights break out in the stadium and a good time is had by all.

Abominable Foreign Exchange

I own an Abominable Snowman hat.   I wore it into work one day, and a nurse from Ukraine asked me, "Vot ees zees hat?" 

I explained that it was the Yeti, sometimes known as Bigfoot or the Abominable Snowman.  I said, "You know, the animal you can only see if you are not carrying a camera." 

He looked at me skeptically.  "I don't know zees animal." 

He "googled" it in Russian with Cyrillic letters.  Then, he smiled.  "Okay,  I do know zees creature.  You see him when you are out drunk with your friends."

Exactly!

Nurse's Note:  This is Abominable Snowman in his summer coat.  I had to draw this likeness since no clear photos exist.

The Best Test

There used to be a commercial showing an old lady griping about the meat on her hamburger.  In the commercial, she repeated,  "Where's the beef?" 

Around that time, my stepfather and I went to a fast food restaurant.  The lunch rush was on, but after he got his food, he didn't step away from the counter.  He unwrapped the hamburger, opened the bun and pushed it at the girl behind the counter.  

"Where's the beef?" he demanded,

She froze.  "Wh--"

"I said, 'WHERE'S THE BEEF?'"

The girl flinched visibly.  Her mouth opened, but nothing came out.  People were staring.

"Well?"  he demanded.

"I don't know," she finally whispered.

"Well, WHO KNOWS?"  he yelled.

Confucius said:  "When three of us walk together, I have two teachers."   Here's what my stepfather taught me that day:

The best test of a person's character is how they handle POWER.    Everyone is charming and polite to their boss.   It proves nothing.  How do they treat the people they have no reason to fear? 

When out on a date, pay attention to how your partner treats the waitress, the maid, the janitor and the busboy. 

That's how he's going to treat you when you've quit your job to raise his children and you're pregnant with your second child.

Online Dating

Online Dating is fraught with problems.  One of the biggest problems is how important myth is to humans.  Everyone wants a "How I Met Your Mother" story. 

The mythic story goes something like this: "I was driving to my flower-arranging class and I almost hit your mom as she was walking her ferret in the crosswalk!"

The myth never goes, "Well, we met online because it seemed we weren't getting anywhere in our relationships and we were beginning to get scared about being old and alone." 

 
 

Or, we could change the myth.  Online dating is a great way to meet a large number of reasonably screened individuals.  But you have to be good at reading between the lines.

    SYNGUL WIITE MAIL, 22, im neerly fivee and a haff feat talle an im purty fat and ayeve gota beerd no jobb rite now im wurkin hard on evur day ritineg a buuk abowt fickshun stuf that is not eveen troo iyll bee dun soone an iyll cell it too sumbody that nose how too reed and ill bee riche im alookin fur a wummin withe a gud jobb its ok iff yew are fatt or sckinnie or if yew haff kids i lyik to dreenk beere an smooke weied and watsh alot off tv too gette ideyahs fer my buuk i doan yous upp two mush watter taykin a byath cuz i doane nyevver tek won hears mie fone nummer

SINGLE WHITE CHRISTIAN MALE, 28, seeks single white Christian female, 18-24 to give birth to numerous children at home and homeschool them, degree from accredited university in medicine or education unimportant.  Must be willing to spend considerable time on her knees worshipping assigned male god.  Mandatory cheerful church attendance on Wednesday evening, Sunday morning and Sunday evening; all said children must attend and be fed/dressed/prepared by aforementioned female.  Hallelujah!!  Female must know her place in regards to the male species--i.e., subordinate.  Must wear long skirts to hide the sinful "V" between her legs and baggy shirts that do not cling to her Jezebel-like bosom and tempt men.  Ability to knit and sew a plus.  Unquestioning obedience and ability to overlook flagrant contradictions a must.  In Jesus's name, amen.  No astrophysicists.

SINGLE WHITE MALE, 18, seeks female 17-22 to have texting races and compare acronyms  (BFF LOL IDK) and see how often we can use the word, "awesome" in a 3-minute conversation. Blonde a plus.

 

SINGLE WHITE MALE, 45,  carnivorous, loves to stalk, gouge, strangle, bludgeon, dismember and disembowel small, furry creatures with large doe-eyes.  Owns both long arms, short arms (foreign and domestic) and one illegally sawed-off shotgun.  Well-travelled, flies overseas tri-annually to murder helpless animals from helicopters with my AK-47.  House is devoted to showcasing the wide variety of my weapons.   My garage has stretched and drying carcasses hanging from the rafters.  Seeks single white liberal female from Portland, Oregon to discuss political issues, live on the beach and sing, "Kumbaya" around a fire. 

SINGLE WHITE MALE, 24, thirteen nipple rings, seven nose rings, six ear plugs, five eyebrow rings and twenty-two neck bars. Lots of outrageous, colorful tattoos of skulls, knives, guns, rock bands, snakes and large-breasted women in provocative postures. I have a tattoo on my penis that says, "Here Kitty Kitty". Seeks anorexic white female, 11-13 for fun times peeing on each other, dressing up as elves and sheep, wrestling in pistachio pudding and hanging naked on a cross while the other person self-flagellates.     
NO FREAKS

SINGLE WHITE MALE, 39, massively obese, wheelchair bound, multiple oozing venous stasis ulcers, high blood pressure, high cholesterol, diabetes, obstructive sleep apnea and chronic renal insufficiency. I enjoy doughnuts, cheesecake, fried chicken, chocolate chip cookies, pizza, mashed potatoes, biscuits and gravy and TV shows.  I like French culture, like eating croissants and brie and putting my cigarettes into one of those long holder things and waving it around dramatically. Last year I studied Italian, including lasagna, manicotti, linguine, farfelle, mostaccioli, fettuccine and cigars. Seeks single white female to stare with slack features at the television while masticating chips and brownies,  hold up my pannus(es), complain about the incompetency and insensitivity of our home-health nurses and run fellow shoppers down with our electric wheelchairs.  No cross-country runners.

Haldol Headache

Studies have been done on the antipsychotic drug, "haloperidol" to see if it prolongs the heart's QT interval. 

What is a QT interval?  What does it do?  How is it measured?  Does the heart rate have to be slow and regular?  Where are my calipers?

Nurses aren't supposed to give haloperidol to a psychotic patient until the QT interval is calculated.  Then, after the dose is given, the QT is supposed to be re-calculated to see if there has been a change. 

Remember--haloperidol is given for PSYCHOSIS.  If a patient is tearing out his IV's and foley, ripping off his clothes and running down the hall screaming and punching nurses--how much time do I have to calculate a prolonged QT?

When the policy of calculating QT intervals came out, the number of psychotic patients plummeted to zero.  It was a medical miracle!  There were no more psychotic patients in the whole hospital.  We still had anxious patients, though.  Lorazepam could be given to calm them down.

Beware of making the cure worse than the disease.  If the right treatment is made too difficult, people will give the wrong one.

I'm giving about 3%

Today I heard a sports announcer say that a player was "Giving 110%!"

Now, I didn't major in math (I don't know what a slide ruler's for) so I could be wrong here, but isn't it impossible to get a number larger than 100 when you are calculating percentages?  The denominator is the whole (represented by 100% in percentages) and the numerator is some portion of that whole.  Right?

So, if someone in sports is giving 110%, are they bringing an extra body part with them?

Nurse's Note:  I wanted to have shirts made up for our unit that said, "ICU Nurses Give 110%!"  but my manager discouraged it.  She said that since we are calculating vasoactive drips, we need to demonstrate some basic math competence so we don't frighten the patients.

HDL Chart

Nurses have a special chart to graph happiness--the HDL chart.  "HDL" stands for, "Happiness Decibel Level".   

Here's last week's HDL chart:

When to Write Other Nurses Up

"Lateral violence" can be loosely defined as taking out your frustrations on coworkers 'cause that's the safest way to do it.  Lateral violence is not as common as it used to be, thank god. 

Sometimes new nurses ask me if they should "write up" another nurse.  Here's what I tell them:

Some things should be written up.  But what?  It can be hard to know.  If you follow a nurse and the IV tubing is unlabeled, should you "write it up"?  What if the patient doesn't have their SCD's on?  What if Zosyn was hung but the tubing was clamped so the dose didn't run in?

Should you fill out an INCIDENT REPORT?  Should you have your nurse manager paged overhead?  Should you contact the hospital CEO?

Maybe.

But, before you do any of that, ask yourself:  "Am I prepared to have this person as an enemy for the rest of my life?" 

Because THAT NURSE WILL BE YOUR ENEMY.  Make no mistake about that.  We are not creatures of logic; we are creatures of emotion.  A nurse who writes up a coworker had better be ready to never make any mistakes, because no mercy will be shown.

You can work with that other nurse for the next 43 years, and she will STILL remember it.

Label the tubing.  Put the SCD's on.  Release the clamp and let the Zosyn run in.  The next time you see that nurse, mention these omissions in a kind, instructive manner.  Make it a learning experience.

This is a 24 hour job.

Hospital Goblins

Hospitals are plagued by several goblins.  These goblins make the nurse's job difficult.

Here are a few of the more common goblins:

THE PAGER GOBLIN

When a nurse pages a doctor and gets no return call, we often hear later, "I didn't get that page".  The Pager Goblin has been at work!

THE TRANSPORT GOBLIN

This goblin is most commonly seen right at shift change. The off going nurse says, "Oh!  This intubated patient needs to be taken for an MRI scan of the chest/abdomen/pelvis!  I didn't see that order.  Can you take them?"

THE TANGLED LINE GOBLIN

This goblin comes into the patient's room and knots the monitor cables, IV tubing, foley, flexiseal, CRRT lines and balloon pump catheter into a ball.  The nurse untangles the mess, but the goblin sneaks in and weaves them together again.

THE MISSING LAB GOBLIN

A nurse draws a patient's blood, puts it into a tube, labels it and sends it to the lab.  Then, the nurse waits.  And waits.  And waits...

Time passes.  The polar ice caps recede.  A new president is elected.  Mars is colonized.

Finally, the nurse calls the lab to check on when--or if--the result might be posted.  The lab technician says cheerfully, "We didn't get that sample!"

This is the Missing Lab Goblin at work.

Step-Parenting

I think the hardest job on Earth is step-parenting. 

This is not exactly breaking news.  The authors of Snow White and Cinderella knew it centuries ago. 

Part of the difficulty of step-parenting lies in the vagueness of the job description.  Are you supposed to be a parent?  Or just a friend?  An adult friend?  (What is an adult friend, exactly?)  Should you try to be a pal, like a popularity contest?  Or more like a teacher?  How much--if any--authority do you have?  

I love my step-daughters and we get along well.  But, nine years ago we adopted two eight-year-old girls from an orphanage in Russia.  They were from the opposite side of the planet from us.  If you get a globe and put one finger on their hometown and one on mine, you can suspend the globe in the air.

They spoke no English and had experienced massive loss, BUT--parenting them has been a stroll through a flower garden in May compared to parenting step-children.

Why should this be true?

Most relationships go like this:  Boy meets Girl

Let's call them, "Tom" and, "Sylvia"...

What's important in this relationship dynamic?  

It's how Tom feels about Sylvia...

And how Sylvia feels about Tom.

This is love in it's simplest, easiest form

Relationships are tough, though.  Think how many fail.  All relationships face daunting odds.

But, if both Tom and Sylvia have children...

The relationship dynamic looks more like this:

How Susie feels about Kate

And how Anna feels about Tom.

How Anna feels about Kate and how Kate feels about Tom...

How Tom feels about Anna and how Anna feels about Susie and how Susie feels about Sylvia and how Kate feels about Erin and how Susie feels about Anna and how Erin feels about Susie and how Kate feels about Tom and how Erin feels about Anna and how Sylvia feels about Kate and how Erin feels about Anna...

All these arrows lead to stress...

Mayhem ensues...

It's tough being a step-parent.

(I didn't draw the arrows that go out to Tom's and Sylvia's parents, brothers, sisters, cousins, nieces, nephews, aunts, uncles, grandparents and friends or the children's other parents.  I wanted to, but Google doesn't allow that large of a post in one blog)

The Plav-Ex Man

I've learned that anything can be delivered these days.  I knew that groceries, horse wormer paste and furniture could be delivered right to your door...but, did you know that you can also have prescription drugs delivered?  Now you don't have to worry with those little pill boxes that say, Mon Tues Wed on their flip tops.

 Every day, your front doorbell rings, and Viola!  The Plav-Ex man is there!

Add caption

Consenting Adults

Lots of nurses get consent forms signed for open heart surgery and other procedures.  

I have heard it argued, "Just ask the patient if the doctor has explained everything to them and then get their signature.  You are only witnessing that it's their signature."

That is a legal nightmare.  Patients are frequently under the influence of many mind-altering drugs.   They often report later that they can't remember anything anyone told them.   If I wasn't present when the doctor talked to the patient, how can I say that the patient understands?  I was at home in bed! 

I'm supposed to ask a drugged, very sick person to sign that they are okay to have a complicated surgery (which I probably don't understand) and then put my name by that?   A lawyer would destroy me in court.  

If I had been to school as long as the average surgeon, I think I might be able to remember to take a consent form in the room with me when I talked to the patient. 

Blackmailers VS Child Molesters

We had a young lady from Thailand live with us for a year through the AFS program.  She was bright and eager, and I learned a lot from her.  Living with people from other countries lets you glimpse your culture through their eyes.  Sometimes the results are--unexpected.

When I took her to our high school to register, she paused in the entryway.  She stared open-mouthed at the imposing pirate statue  that guards the entrance.  The statue is every stereotype of a pirate--black hat with the Jolly Roger, peg leg, eye patch. 

The young lady turned to me, swallowed hard and asked, "What is that?"

I explained that it was our mascot.  Did she understand what a mascot is?  It's a symbol to fight or rally under.  Our school's mascot is the pirate.   Did she know what a pirate was?

This young woman--born and raised in Thailand--answered quietly, "Yes.  A murderer on the sea."

So, she really DID know what a pirate was.

Sex Education

Let's talk about sex.

First, can we just admit that sex is a weird thing to do?

No?  

Imagine someone came up and poked their finger in your ear.  Would you say, "Ohhhh, yes! YES!!  MORE!! MORE!!" ?

Or would you yell, "Get your finger out of my ear!" ?

Another person shoving a portion of their body into one of your orifices is bizarre.  What kind of evolutionary sleight of hand caused us to do this?

And what kind of sick pervert WANTS to stick their finger into someone's ear?  There's dirt and skin flakes and orange wax in there!  Why would anyone do it? 

Why would anyone PAY to do it?

But, wait!  It gets worse!  Sex has many bad outcomes associated with it. 

Here are some of them:

 Nasty smelling pus dripping from unmentionable parts

Painful warts, blisters and growths cropping up on other parts

Your body insane with hormones, swelling, distorted and mapped with stretch marks

After nine months of waddling around, an additional eighteen years of discomfort

And, the ultimate bad outcome...

You wouldn't think that sex would be a difficult thing to give up.