ETOH is out of control

 It seems that COVID has hit ppl hard right now. So many of our patients are in due to ETOH abuse/detox issues. 

I wonder what happens in one's life for a person to give up sobriety and hit it so hard that you cause yourself to have a seizure from hyponatremia?!

Any of you know about hyponatremia and why it can be so dangerous? When you have someone's Na level so low that they have a seizure or fall into a coma, you really want to make sure that it increases slowly. If it increases too quickly, you can get demyelination, brain edema or brain herniation.

Unfortunately, my patient had other thoughts in mind. 

We were doing serial q4hr electrolyte checks to make sure we were aware of where the sodium levels stood. I checked the level and then my partner encouraged me to go on break. I advised her that she needed to make sure she was looking for this value and to ensure that the MD was made aware of the level.

I came back from break, our usual time frame and yet there was still no level back. We are in the midst of doing team nursing and so I had four patients to tend to - one needy patient, one trying to climb out of bed and pull lines, and then I had a legit sick patient.... plus all the usual hourly things that I was responsible for.

So of course the sodium level was overlooked, and lab didn't call me because said level normalized and they don't call anyone for "normal" values.... shitty in this case.

Long story short, the value rose much too quickly - like by 13 points in like 4 hours.... damn. And the MD comes down the hall saying "hey, why didn't you call me with this value like I told you I needed you to? They patient has been getting too much of this kind of fluid for at least 2 hours".... I advised him that I couldn't help it, when I got back from break the value wasn't returned and then I got busy with these other ICU patients.... thankfully he's an understanding MD and was like, ok, change the fluid.... which I did promptly.

Doing q1hrly neuro checks denoted no changes in said patient's neuro status thankfully. Even 24 hours later, no obvious damage was noted. It didn't seem to matter what fluid we put this patient on, because the sodium value still rose of its own accord.

I'm sure that in a couple of days the patient be back in their own abode, going back to the alcohol that put them in the ICU in the first place. Such a shame.

Long term effects from COVID 19

 Being on the front lines and seeing this terrible illness ravage people is not easy. I regularly get frustrated that the population at large just don't seem to grasp the fact that COVID is not just life threatening but even when you have a "mild case" of it, that it can affect you for the rest of your life.

I've recently cared for someone who caught COVID and is now extubated and "recovering".... but is left with permanent cognitive issues because he was starving for air for too long and it starved his brain of the oxygen it requires, leaving him with an anoxic brain injury. Never will he work again because he can hardly talk, can barely move, and the brain injury makes it difficult for him to even respond. It will take him years probably to walk again, with many months of physiotherapy involvement to gain strength. He will need speech-language pathology involved so that he can learn to swallow and talk again. He will need occupational therapy to help with the daily activity of living.... with being able to manipulate a cup, spoon and hair brush. Things that we absolutely take for granted.

I know of two staff members who have caught COVID from work. Both are young and healthy. Thankfully they did not need to be hospitalized but required months to get back to functioning levels. Both state that they have lingering lung issues almost a year after they caught this illness. They say that going up a set of stairs makes them gasp for breath and forget being able to work out, that's just not possible. 

There are many patients that our ICU has cared for who have caught this illness and while they weren't hospitalized because of COVID but because they are experiencing the after effects of this illness - having a stroke or a heart attack. Or experiencing renal failure because their body sent tiny clots to areas of their bodies and caused damage. We've had patients go into DKA because of COVID after the fact because it taxed their system and it couldn't cope with stupid COVID.

But I also wonder about the after effects that COVID will have on the rest of us who don't catch COVID, but still are affected by it because we're wearing these masks for such extended periods of time. I wonder how much CO2 we are rebreathing. If anyone has seen someone whose CO2 has risen, they can attest that these ppl kinda go coo koo. Anyone who is relatively healthy has a pretty good buffer system in play and so their body buffers this rising CO2 - but it has to have lasting effects on our body. I wonder about the kids who have to wear masks for 8+hrs a day when they go to school. Are we going to see issues with psychiatric conditions in 10+ years? Are us adults in 10-15years going to see more psych conditions or dementia/alzheimers? 

I wish that people would stop being so damn selfish and stay home and away from people. Stop visiting anyone, unless they are bedridden and require daily care. Otherwise, stay away. People don't understand or just don't care - or they think "that won't be me" - but with the way the numbers are going - damn right it will be - it will be you.... or someone you love. And then what?! Are you going to turn around and be "20/20 is hindsight, golly I wish I had done things differently".  How is that going to help when you no long have your parent/grandparent/spouse/brother/sister/cousin, etc.... around because you just had to go visit them. 

You and they will survive being apart for a bit. If it keeps ya all alive, it's worth it!

Taking care of crazy in this crazy time

 There was a mix up in one of my shifts the other week so I ended up going into work late. When I get there I am advised to seek out our teammate and inquire what pt she wanted me to take from her. On the board I saw that one of them was CIWA = ++++work.

And of course when I asked said teammate, she responded with me taking on the CIWA. I joked with said teammate about me seeing what type of teammate she is, giving me that CIWA.... ok, np I shall take up this noble cause.

Then when I opened our charting program, I see on the board that the other pt she could have given me is a recovering COVID pt..... one that I can't even take in the first place. So I would have been stuck with the CIWA anyways. Guess it was just my lot in life for this shift to end up taking this on.

Well so be it....

Then we got into the thick of it.... the CIWA pt telling me that I took away their scissors and how I should give them back and that it was against the law to take them and if I didn't give them back that they were going to sue  me!  Ha, have fun with that one coo koo.

Oh did I forget to mention that this person is bat shit crazy and in 4 point pinel restraints?! Ya person's a frickin crazy and on CIWA! Oh yay!!!

I told them that they could go right ahead and sue... sue away!

Then I was told that I shouldn't lay my hands on them - when my hands were within their eye sight and holding onto the side rail up by their head!

Then I had a colleague come in and "suggest" that we pull said pt up. I was like, hell why not. So away we go and do that, and she turns to me and says "touch me and I'll fuck you up!" - oh goodness we had a good laugh at that one..... she's in 4 point pinel restraints. She aint doing any touching!

A couple of hours of trying to keep her in the friggin bed, then she's all serious when I go in and check on the levels of meds running through the pump and she turns to me all serious and says, "when I get out of here, I'm going to find and kill you". I didn't even deam to respond and simply nodded my head and walked out of the room. No point in even responding to the delusional. Besides, even if she could follow through on that, I am highly unfindable as I have an unregistered phone number and the house I live in doesn't belong to me.... so go ahead and try!

This person was nearly impossible to reorient, but I did try several times. You can only help crazy so much. 

Hell, the person was trying to climb out of bed with 10mg/hr of Versed infusing as well as them getting Valium 10mg IV q1hr PRN.... like I said, crazy!

And that's what I dealt with all night long... it was a long shift to say the least. Thank goodness I don't have to deal with CIWA pts often.

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.

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?!

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.

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.