Wednesday, November 18, 2020

14+ units and counting

 It's hard to believe that amount of blood one has inside the body.... unit it starts to be expelled from the body.

I had a pt who had a GI bleed... and anyone in healthcare will know the smell that the breakdown of blood creates.... the smell of melena stool.

I was lucky enough that my pt was expelling things fast enough that it wasn't smelling like that. When I got the pt, he had had several procedures in an attempt to stop the bleeding internally. We thought it successful.... during my shift he only had two BMs - and it didn't have the clots and bulk that it did before. I thought I was pretty fortunate. I also thought the procedure successful.

Until the next shift when I ended up cleaning up six BMs. Again, no real melena smell. I figure where they thought that they had an issue and thought that they had fixed was what would stop the bleeding. Clearly though they did not... based on what the stool looked like, I imagine it to be small bowel, but close to the large bowel. Because it's not like it was bright frank blood but it was broken down some - but clearly it wasn't in his bowels long enough for the blood to be broken down to the point where the enzymes interacted with it and caused the typical melena smell.

Another scope another time. Hopefully this time it was successful.

For all the bleeding this poor soul has undertaken, he ended up with 14+ units of PRBCs.... his blood volume replaced twice+ over. Hard to believe, but hey, the human body is miraculous.

Monday, November 16, 2020

Full of bullshit

 We're almost at a point in our ICU that we can't accept any other patients. COVID's second wave is starting to take over our ICU. At last point we had 5 pts in our ICU and another 7 pts on the wards. And of course our numbers in the province are only getting larger not smaller so it's inevitable before we get inundated with COVID pts.

I previously asked our manager what the plan was for non-COVID ICU pts when our ICU is COVID pts - the powers that be indicated that they would cross that bridge when they come to it.

The last wave had some of our staff in the unit above with COVID ICU pts - a dangerous endeavor as the monitors for the pts were all inside the rooms, so it made it difficult to monitor pts accordingly. I'm sure they will be doing the same thing very soon.

Being that I have a workplace accommodation that I don't have to work with these pts, I've asked what they plan to do with ICU-trained staff who all have accommodations.... there's always going to be ICU pts that still need assistance.... until such a time when our hospital is overtaken with COVID pts. I'm sure that it will happen, look and see what's happening in the large cities in the US. Guaranteed that's what's going to happen here in Canada.

Hell, it happened with the first wave and everyone is saying that this wave is going to be worse. So I can't see us not getting hit this time around. We were actually quite fortunate that we weren't inundated with COVID pts the first wave. Sure we had our fair share, but at least it was manageable. I have no idea what they're going to do this time around.

I also think that the powers that be need to sort their shit out on who they provide resources to. I mean, intubating a 90yr old (IMO) is just a waste of resources when the second wave is just beginning. It's not likely that they're going to survive COVID, so why not just attempt to make their death as comfortable as can be?!

Saturday, October 24, 2020

On to markings

 Received a pt a little bit ago, he had gone to our sister hospital for a cardiac catheterization.

They attempted to do a radial approach and was unsuccessful so they did the approach through the femoral artery. Now, one of the known complications is nicking the artery and causing bleeding. This poor soul was one of the unlucky few who experienced this and ended up with a retroperitoneal bleed - essentially, where they nicked had bled into his abdomen, creating a large blood clot when it stabilized.

It's obviously a medical emergency because your belly is a LARGE area and you can bleed into it quite quickly so the nurses that were there were laying all their body weight onto the poor gent in attempts to save his life.

Unfortunately, they didn't think it prudent enough to both to tell the poor gent that they were trying to save his life by doing just this. Now, do remember that this action is EXTREMELY painful to the pt. So of course this pt was fighting the poor nurses trying to save his life. I'm sure they could have saved some of the grief that they were receiving by just simply teaching the guy a few things!

So when I got him he was bruised, but not overly so. As soon as I received him on shift I examined his groin, how much bruising he had to the area and his abdomen for any subtle or blatant bruising, as well as his lower back because it can show up there as well. All things to keep an eye on. Stupid me though didn't mark the borders of his bruising (more on why that's important in a just a min) but just made a mental note of where and how much bruising was there in the area. I also checked out what was going on with his dressings to make sure that they were dry and intact, or whether there was any previous or active bleeding (femoral and radial areas). Both were as they should be, clean, dry and intact.

So off my pt goes to sleepy town and in the morning when I wake him for blood work, he tells me that his belly really hurts. I asked him if he needed to void, he told me no but I told him that he needed to attempt to void anyways. So off he goes, does just that and questions why he had to pee so much when he didn't feel the urge to go. So some education time later, I told him I needed to see his nether region to check out the bruising and whether there was any swelling. One of my red flags went up because I noted that his mons pubis (where all your hair is above you lady/gent bits) was more swollen than at the start of the shift and another flag went up when I saw that his bruising had extended in towards his mister bits. 

I asked if his pain had changed since voiding, thankfully he indicated that it had lessened but was still present. I went an looked to see whether my CBC was back and examine what his Hgb (red blood cells) were and how much things had changed.

From my pt returning and having his Hgb checked at ~1000hrs it was 127 then at 1600hrs it was 121 but when I got the result at 0600hrs it was 108 - so in almost 24hrs it had dropped 19points - significant! 

Off I went to tell my charge nurse all this and ensure that i was doing the right thing by getting a hold of the physician... she agreed and off I went to call him.

I advised the Dr of all of the above and asked what they wanted done.... I got complete silence. I understood that I likely woke the Dr up but still expected something more. So I asked whether he wanted me to just monitor it or do something more extensive. I was told to monitor it. I asked how normal the spreading of the bruising was... I was told that gravity would naturally spread the bruising down the leg and into the groin and nether bits, but that marking is prudent. I advised that I had done this prior to calling. Then I got silence again. I was expecting more from this Dr, some sort of direction to take. I asked if he wanted me to repeat the CBC, say like 6hrs later.... I got a "ya, sure". Ok, I guess I'll take it. The good thing was that at least I could document it all. I did my part in all this.

Marking my pt was quite interesting, having to get down and dirty really.... getting handsy with his bits and pieces so that I could mark where the boundaries of the bruising were. He was a sport though and took it all in stride.... "oh I wish this could have happened when I was a 19 yr old!" HA! 

Unfortunately, when I came back 12 hrs later, he was transferred out to give the bed to someone who was sicker so I don't have any notion as to how things ended. wahwahwah. C'est la vie, such is the life of a ER/ICU nurse.... we don't always get to know the outcome of our pts after they head out of our area.

Monday, September 7, 2020

COVID baloney

 Friggin Covid. I'm sure there's a consensus that it sucks. For me personally, I haven't had to have much to deal with this on a patient level. When we started to get COVID pt's in our ICU, I got a workplace accomodation as I have a IgG deficiency and I also take Humira which further decreases my immunity levels. My IgG deficiency tends to affect my lungs in particular and so I had a conversation with my MD about the accomodation to not have any suspected, presumptive or confirmed cases of COVID. The notion is is that if I were to contract it, that I would be one of the unfortunate few who would require ICU admittance and probably be intubated. So to protect me, I got it done. Paperwork was sent off to Oc Health and it was granted.

Then when they were reevaluating the accommodation status of everyone in the hospital, mine was as well. I explained to them why I needed the accommodation and what not and they told me that they would speak to the Oc Health Dr and get back to me. They did, and I was told that the Dr had advised that I be redeployed permanently out of bedside nursing!!! I told them that I appreciated that they care enough to recommend that but that I was kindly declining that. I told them that I had mitigated my risk by leaving ER and moving to ICU... that in the ICU I am generally 1:1 or 1:2, unlike in the ER when you could be up to 1:5/6.... and when the pt finally gets to ICU, we generally have an idea of what they have and there are generally treatments available for whatever ails them and so IF I were to catch whatever a patient has, there is the treatment available. And if there redeployed me elsewhere, med-surg is generally 1:4 and up to 1:8.... and if they put me in a clinic I could be exposed to as many people as 100 per day.... so obviously the risk is smaller in the ICU when I'm only going to be exposed to as many as 2 ppl. 

When I explained it that way they responded that I had clearly given this some thought.... of course, it is my health and life we're talking about!

So I've been trudging along in the ICU, not having to care for COVID pts when an unexpected thing happened...

I had gotten my hot drink from the coffee place in our hospital and was walking to my unit and somehow pinched a nerve in my neck. Holy crap was it painful! So I was on modified for a bit and when our area of the world opened up a bit and I could go see a chiropractor and he put me on further modified duties and so I was taken out of ICU because they couldn't accommodate my restrictions.... no bending/twisting, no lifting over 10 lbs, no raising my arms above my shoulders and no pushing or pulling. He figured that I was compensating for my neck with my lower back. So then I became a COVID screener and have been there since, goodness I miss being a nurse!

Well then one particular day I had a particularly busy shift and when I went to the chiropractor and did an adjustment on my back, a very minor one on my lower back in particular, I couldn't put any pressure on my lower back, I had crazy pain travelling down both of my legs and I couldn't stand up. The chiropractor gave me some numbing cream to put on the area and in about 20 min I was finally able to stand, but lifting my feet was still an issue and it still hurt to do so. These symptoms got better with time thankfully but the chiropractor thinks there's something structurally wrong with my lower back and stated that I need a MRI to figure out what's going on and that I shouldn't go back to full duties until I get this done. Not that hubby agrees with this. He wants me back in the ICU ASAP, be damned if I get hurt again or more.

So for the time being I screen ppl for COVID symptoms as they're coming into the ICU... behind glass and in proper PPE. I hate it, but it's an easy job for sure. We'll see where this takes me.



Saturday, July 4, 2020

WTF OR?!

To hand someone over that is basically dead and say that they are only hemodynamically unstable in not OK.

We knew that we were getting a patient who went from our sister hospital's ER and transferred to our hospital's OR for emergent surgery. We were told that this person required massive blood transfusions - weren't told what they received but that the code for the massive blood transfusions was cancelled - making us believe that the person we were getting was stabilized. I told everyone that it was going to be a "gong show".

We tried to look up in the system something about this person because all we knew was that they were really young and they had an inferior vena cava filter and that it had eroded there and the pt was bleeding. We knew that clearly this person had other shit going on if they were that young and required this. The crazy thing is that the chart had NO information from doctors from the last four days worth of ER visits! No information listed to blood work that was done over the last couple of days. How in the world could this person not have ANY blood work any of the previous days considering they were on blood thinners and had this filter in place. You would think that they would do blood work (BW) - such a basic thing. On the fourth day they finally did and their INR was 12!!!!! Oh, and their Hgb was 30!!! Shame on the ER for not doing BW on any of the other days, they for sure would have caught things declining a whole lot sooner.

I was the assist nurse that shift, helping those who received admissions. The nurse had indicated that they hadn't done an admission yet - surprising cuz this person had been there longer than I. So I advised them that when the OR called to ensure that a proper report was given because often they will just tell us that they are coming and asking whether we're ready. So I told her to make sure that she found out what state that this person was in. I advised her to find out what meds that this person was on because I absolutely believed that this patient would be on meds to support their BP, guaranteed and you don't want to be chasing your tail when they arrive, trying to get these meds infusing while trying to settle your patient. For some unknown reason the pumps they use in the OR is different than the ones used in the rest of the hospital. Therefore it was pertinent to find out the meds they were on so that they could be ready to change over to our system. Of course I was right when they called and advised that they would be coming in 10-15 min and then subsequently hung up. The nurse, listening to me, called them back and received a proper report.

When the OR people brought the patient to us the lines were a mess! While myself and another nurse were getting things sorted out and attached to our cardiac monitor, I pulled all the blankets off and saw that they had two intraosseus (IO) and several peripheral IV lines and then a single lumen central line (SLIC) - and they had pressors running but no blood or even IV fluid. The pt also had a art line showing their BP and when attached to our monitoring system we could see immediately that the art line BP was seriously low => something in the area of 50/25.... not enough to sustain life for sure. And the nurse asked the anethetist WTF and was told that the art line wasn't accurate so a BP cuff is quickly put on and the BP was basically unchanged - so immediately the ICU Dr asks for a pulse check.... nope, no pulse and so we immediately start coding this pt.

We restarted the massive transfusion protocol and start pumping fluids in, hoping that we can revive this person. Sadly we coded this person for quite a long time and couldn't get them back.

Now I'm left with the feelings of this whole situation. I don't understand why the OR would cancel the transfusion code... did they even check pulses before sending us this person. Were they just trying to offload this person on the ICU so that they could be relieved of the fact that this person did NOT die in the OR?!

We had a debrief after TOD was called. We talked through this all. We talked about how hard it was for information to be found about this person's current medical condition and any recent blood work. We couldn't understand how the OR did NO blood work while the patient was in the OR. Why would they cancel the transfusion protocol if they had no numbers to back up cancelling it. They had NO idea what this patient's Hgb/Hct was when they brought them to us in the ICU.

ICU didn't stand a chance of saving this person because so many people before us failed this person. To learn that this person just celebrated their birthday and then to learn that they were a refugee made this death even worse. Such a short life to be cut short when so many other steps could have been taken to save this person.




Friday, May 29, 2020

Ouch

We have a coffee shop in our hospital and several weeks back I picked up my tea and headed to my unit. But on the way up I managed to hurt my neck. Couldn't tell you how.

I went home that day, goodness the pain was intense. But it gradually eased up and I went back to work after a bunch of days off. I got lucky that I had cardiac patients and it wasn't hard on my neck and got through my couple of shifts. 

This last week however, I had a typical ICU patient and managed to tweak my neck again. Goodness it hurts. I get this shocking pain down my neck, through my shoulder and down into my fingers. I know I pinched a nerve at about C6-ish. Confirmed by the ER MD. No test though, so don't really know why exactly it happened.

Regardless, I lost another day of work and had a couple more days off afterwards so I rested as much as I could - doing my physio to help myself.

But to no avail, still hurts like a mother sucker - so I let my family MD know about it and so now I'm on modified duties. Also, I need to have physio and a chiropractor would be helpful, but can't because everything is still shut down. Sad face!

Had to work last night, thankfully we had an ICU patient that didn't require any pushing/pulling,turning/lifting - a nice stable DKA for me thank you very much.

Even having a pt like this caused pain - but at least it was manageable. We'll see what this weekend holds as it's my weekend to work. So this should be interesting to say the least.

Wish me a speedy recovery.

Wednesday, May 13, 2020

When the will is overrun by family decisions

How does it come to be that families can make the decisions for family members in critical care, when they themselves have made it known what they would choose for their life and their death?!

When someone comes in for a fairly basic surgery (albeit an emergent one) and have a perioperative MI and when they are woken are told what has occured and that they require a cardiac catheterization - to which they decide that they would prefer to not undertake this.

The surgeon (or whoever it actually was - a MD none the less) had a frank conversation with said patient and indicated that the catheterization wasn't performed, that a major heart attack would occur.

The patient, in right mind, made the decision that they would not have this procedure performed, even if that meant that they would have a heart attack.

Then advised that they could die if this occurs, the patient indicated that that was alright and that should a heart attack occur, no CPR/defib or intubation occur. Meaning that nothing should be undertaken if a heart attack is to occur and survival not be possible.

Now the twist in this entire story is the fact that the health care person who had this conversation, and could write it down and make it official, DIDN'T WRITE AN ORDER!!! All they did was put it in their notes. Friggin idiot!

So of course this person had a massive heart attack and went into an unsurvivable cardiac rhythm (VF to VT) and they called a code and managed to get this person back.

Then of course it's family who decides what the next steps will be. Even though the family find out what the patient said to the MD, they still decide to do everything in our power to get this person through this.

Now after some time has passed, this person is basicly a vegetable - doing very little more than lying in bed and existing.

I feel for this patient - ending up in this state after indicating exactly what they don't want and because of an oversight, ended up having everything done they didn't want. Now they have to live with the consequences of this and what their family is choosing for them.

If I were them, I'd come back and haunt my family after I actually get to die. That's the least that they deserve for making me suffer as a vegetable in bed. Such a pity of a life. No quality at all.