Pulling into the Frustration Station!

Steam Locomotive JS6546
I was STEAMING

I had a patient recently that had an interesting hospital course of action. To the nurses, it was clear what was going on. The residents and MD disagreed – and did not share this information with the nurses.

This patient, who was an octogenarian, was Covid-19 positive. She was admitted for altered mental status and decreased blood pressures. Her D-Dimer was high. Now for those of you working with Covid patients, it is not unusual to see high D-dimers. Those patients are treated with high dose Lovenox to prevent clotting. Altered mental status and low blood pressure is also common in the elderly when sepsis occurs.

This patient was only getting standard subQ heparin Q8, and they had started her on midodrine for her low blood pressures. She was out on the medical-surgical floor when the staff out there decided her O2 saturation level on a non-rebreather was too low and she needed to come to the critical care unit. I accepted the patient as a STAT transfer, and once she came to me, I realized that everyone was freaking out.

Her O2 was 100% on the non-rebreather. Her blood pressures, taken hourly, were all in the 105-115 range systolic and 65-75 diastolic. She wasn’t short of breath. She was alert and oriented, and was quick to tell us that she didn’t live with her daughter, but that her daughter lived with HER. We all got a chuckle over that.

We got her settled, put her on continuous monitoring, and watched. Nothing happened. She remained stable. I was thrilled to have a completely stable “critical” patient. The next day, I noticed that her oxygen went down to the 80s. I went into the room and found her with her oxygen off talking on the phone. The mask kept bumping into the receiver while she talked so she just slid it down out of the way. I replaced the mask and she recovered, but true to many Covid-19 patients, it took quite a few minutes to get back to the 99-100% range I had been seeing. Mystery solved. This is most likely why she was so low out on the med-surg floor. They probably didn’t wait that 10 minutes to see how she did before checking her oxygenation status. I called cardiopulmonary told what I witnessed and we switched her over to a high-flow nasal cannula so she could talk on the phone without the mask bumping – she did great. Again, O2 saturation was perfect in the 95-100% range, and never once did I notice any tachypnea. The patient was happier as well.

Later on that day, the ultrasound team came in to check her legs for DVT. I never got to read that report as we had several critical goings on in the unit at the end of the day that took precedence. It turned out she did have a small DVT in her lower leg. It wasn’t until I was giving report that it happened.

I received a phone call from a local hospital stating they had received the transfer of my patient and was calling to give me a bed assignment.

WHAT.

THE.

HECK.

I called the resident, explained that I was in the middle of giving report to the oncoming staff and that I had no idea that shipping this lady out was on the table and WHY ON EARTH WAS SHE EVEN GOING OUT ANYWAYS??

He came over to explain. The physician team felt she had a submassive pulmonary embolism and needed immediate transfer.

She had no chest CT done.

She was not on a heparin drip that indicated this concern.

She was not short of breath in any way.

She had no clinical indication whatsoever that this was going on. This was just a sweet old lady in bed who took her oxygen mask off to talk on the phone.

I was highly frustrated. The MD team could have taken 2 minutes out of their day to TALK TO THE NURSING/CARDIOPLUMONARY staff to see how she was doing. Or I don’t know, how about updating us?

Physicians of the world: talk to your nurses.

Wherever you are in your nursing journey – I want to encourage you –

I have noticed a running theme in the last 9 years I have been in the nursing world. And that theme seems to play out in everyone I meet: you must be better than all of your peers. I see this time and time again. Almost every nurse I meet feels like they must impress me with their vast knowledge. If I say I do it this way, a great many nurses will tell me my way is wrong, and the way they do it is the correct method. This is a DAILY struggle. Why do we all have to one up each other?

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When I took the position of resource nurse in my unit, one of the other nurses had a BIG problem with it. She told a new employee how my unit stunk, and that all the nurses there were incompetent, and how I was not qualified for the position. She promptly took another position in another part of the hospital, and now rolls her eyes at everyone from our unit. We all breathed a sigh of relief at her leaving.

But the damage was done. Just yesterday, I had probably one of the hardest days on our unit, and was overwhelmed at a few points in the day. That nurse’s words kept coming back to hurt me, over and over.

Maybe I AM incompetent.

Maybe I am not worthy of this position.

Why did they choose me?

At the end of the day, her poisonous words from two months ago had taken their toll. I was completely defeated, and the two new-hires I had been precepting all day probably saw this at the end.

I am now more determined than ever to spread hope and love throughout my career.

You, whoever is reading this right now, YOU are a fantastic nurse TODAY. You might now be the smartest and the quickest in the field you are in, but you are everything you need to be TODAY. Keep up the great work, lift your head high, and know that you are exactly where you need to be. Tomorrow you will shine a little brighter, so kick off the grime and wash off the poison from others who do not see the greatness within anyone besides themselves.

You are a wonderful nurse.

You are a fantastic student nurse.

Keep up the fight, and stay strong.

(((HUGS)))

Another hard day at my dream career

I am in a small hospital ICU as the resource nurse. Now when I took this position, the unit I work in was quite different from what it is today. Then we had 4 beds, with 2 patients per nurse. Our days while sometimes very busy and sometimes quite hard, but they were always – doable. The quite hard days were far and few between which allowed us to forget about them easily.

With the advent of Covid-19, however, this has all changed. We have hard days almost every day now. Too many patients are suffering to make positive outcomes the norm. Our hospital decided to open all 8 beds in our unit, and staff accordingly. My job as resource/charge nurse, while simple before, is now becoming difficult. Why? Because all of our nurses are leaving to go to where the money speaks: Covid-19 travel nursing. Honestly, I cannot blame them. The money offered is fantastic compared to a small town hospital. I understand their decision, but it leaves me to train all the new staff.

Today I had 2 orientees and 2 nurses that literally got off of orientation the day before. One of those new nurses is a new grad. One orientee had no ICU experience. We ended up intubating a unstable Covid patient, advocating for a central line for the same patient because the residents were going to wait until the surgeon on-call got out of surgery do put one in and she needed one NOW, doing a lumbar puncture on another ventilated patient (this was attempted the day before unsuccessfully as the doctor pushed the patient so far into the mattress the day before that the tube became bent in half and dislodged. We had to take it out and reintubate), move out two patients to the med-surg floor, receive another med-surg patient that was Covid (no Covid beds on the med-surg floor so the ICU gets them all), received one more ventilated patient that had only one working IV, call a tele-consult for another patient (this process is so time consuming), and we were all. Just. Swamped. We have no CNA, no secretary. The phone rang all day from family members needing updates.

At 1800, one of the residents came up to me and told me that the hospitalist wanted us to prone the slightly stable covid patient we had intubated earlier that day.

And I said NO.

NO. NO, we are not going to prone this patient right before shift change. NO. She was barely stable, barely sedated on drips that were at the maximum level, and her O2 sats were in the low 90s at best…and she was quite the kilogram heavy patient. NO. This is not right time to do this. By the time they got enough staff to go get the proning bed, gown up in PPE, start the paralytic, and go in to flip the patient, it would be well past 1845, a great time for let’s say… the tube getting dislodged? How about a drop in O2 saturation that was fatal, right at the end of the day?

NO.

I have never said no before.

I have always done everything that was asked of me at work. I have never said NO!

I called the supervisor, confessed, and told her how to spell my last name if she needed to write me up.

She laughed and agreed with my decision. And after all the worry that I was making wrong decisions all day long, that little bubble of joy made me feel so much better.

MIROCO Light therapy unit

***THIS IS A REVIEW OF A PRODUCT. IT IS NOT INTENDED TO REPLACE TREATMENT FOR DEPRESSION***

I purchased mine from Amazon. I am not affiliated with Amazon or Miroco in any way.

Miroco Light Therapy Unit

I purchased this neat little light therapy unit the other day. Every year I tend to suffer from SAD (Seasonal Affect Disorder), and I thought I would try to stave it off this time.

I have used this unit for over a week now, and I have to say that so far it is working. Light therapy, when done correctly, can reduce SAD in many individuals (Reeves, et al., 2012). Every year I just get so down and in the dumps. I am hoping this year will be different. Fingers crossed!

I am the girl that chooses the sunlit table in restaurants all the time, to the dismay of my friends. I feel like a plant, constantly seeking the light. As nurses, most of us work 7-7, and whether we are inside all day in artificial lighting or asleep after working all night, during the winter we just do not get the same amount of light.

This great little unit is budget friendly, portable, lightweight, and has adjustable settings. It delivers 10,000 lux at its brightest setting.

The only drawback I have about this unit is the ugly light it produces. Since it is not a home lighting product, I can easily get over the ugliness for the short time I use it!

Reeves, G. M., Nijjar, G. V., Langenberg, P., Johnson, M. A., Khabazghazvini, B., Sleemi, A., Vaswani, D., Lapidus, M., Manalai, P., Tariq, M., Acharya, M., Cabassa, J., Snitker, S., & Postolache, T. T. (2012). Improvement in depression scores after 1 hour of light therapy treatment in patients with seasonal affective disorder. The Journal of nervous and mental disease, 200(1), 51–55. https://doi.org/10.1097/NMD.0b013e31823e56ca