ICU Bed Vs. RT's Foot.

You can barely see it in this pic, but I ran into a little trouble at work Monday morning. Errrrr, more like it ran into me. I had the SICU, and I get a call that we are transporting one of my patients for a stat head CT. Oops, they forgot to call me, and transport is already there and ready to go. So instead of hooking up the transport vent, I decide I am just going to bag the patient fo a quick trip down and back. Off we go.

We ge down to CT without a hitch. Once there, I move to the other side to the bed to arrange IV lines and such for a safe transfer from the ICU bed to the CT scanner. That is when the very sweet patient transporter starts pushing the bed. Right over the top of my right foot. The ICU bed that weighs as much as a car, without the squishy air-filled tires.

But I am a trooper. I stay, balanced on one leg, bagging the patient until the ordeal is over, then hobble to the ER for x-rays. This is where I learn that the male RNs in the ER really are knights in shining armor. Poor Ben gets down on his knees and takes my shoe and sock off. My rubbery shoe. After working 11 out of 12 hours. And he says nothing, even tough I am crying and blubbering about smelly feet and stubbly ankles. Then Steve comes in to make sure I can walk on crutches. Don't even get me started on Norm, the security guard who wheeled me into my room and filled out the incident report for me. They are all angels. You just can't see their wings through the scrubs they wear.

As for me? Outlook not so good. I am on crutches. I am off of work, which I hate. The employee health nurse was teasing me about my control issues and workaholic tendencies. She asked me if I was taking my pain meds, and I told her no, that they drug me up, and she laughed and said that it is because they make me lose control of the situation and sleep. She's probably right. So for at least this week and next, I am just a student.

And I am bored.

Sticky Situation I Found Myself In

A Patient is completely alert and oriented. She is intubated and has been on a ventilator for days, thought the initial problem had nothing to do with her lungs. Now she is awake and demanding to be extubated through hand gestures. Her vital signs look amazing. She has an order for a wean in the morning. But she insists on now. The family is called in to speak with her, and the family agrees with the idea of honoring her wishes. Her doctor, on the other hand, did not give the order, but did not tell us not to extubate, either, but simply made the statement that extubation would be at her wish and not his order. You put her on a t-piece and monitor her. There is absolutely no change in vital signs for 2 hours. You get a blood gas, and it is textbook-perfect. What do you do?

I'll tell you what I did. I pulled the damned tube, documenting heavily on her stability and the family and patient's wishes. Apparently, this has been the talk of the MICU. My director, critical care coordinator, and supervisor have commended my actions, saying I did exactly what I should have done in that situation. The director has even gone so far as to copy my charting to place in my personnel file along with a typed commendation from him. Only one pulmonologist has said anything. She wanted to know if it is "standard practice to extubate a patient in the middle of the night without a physician's order". Absolutely not. But to honor a patient's wishes while safely monitoring the patient's cardiopulmonary status...My intent throughout the whole ordeal was to watch for anything that would indicate that she would not be able to handle extubation. Had anything come up, I would have immediately had a discussion with the family regarding my concern. But nothing did. I could find no reason to leave her intubated against their wishes. And the outcome has been phenomenal. She hasn't needed so much as a breathing treatment since I did the deed.

So my Big Boss is recognizing me, stating that I have done a tremendous job for the hospital since I have been employed with them. Up until recently, I didn't even know if he knew that I work for him. But according to a phone conversation this morning, he has been getting a lot of positive feedback about me. Kind of makes my ears burn a little bit, wondering what has been said and when. But overall, it feels great to have your hard work recognized.

No Summer

Okay. I have been through hell and back over the past few days. It all started with physics. As in I dropped it. After 3 days of studying non-stop, I was not at all ready for the first exam. We were to have an exam every 3 days over 10 chapters each. Nope. Not happening. I decided it would be better to take the class during a traditional quarter instead of the 4 week long summer sessions. So.....
I went online to look at my account for UC to see what this would do tto my tuition. This is when I found out that I would not be getting my S.M.A.R.T. grant. Uh-oh. Furthermore, they did not kick-in my metropolitan tuition rate that I became eligible for when I changed majors then picked up the double major. Big Uh-oh. The grant left me about $1300 short, then I was assessed a $4800 surcharge for being out-of-state. The moral of the story is that I ended up owing UC over $2K. Lovely.
First they told me that it had to be paid this week or my classes not only for summer, but for fall as well, would be cancelled. I asked about what would happen if I just dropped the rest of the summer courses, and that was no good either. In stead of owing $2K, all of my loans would drop out because I would no longer be enrolled, so I would owe 50% of my tuition with no aid. About $7K. What to do? And regardless of what I do with UC, I cannot just transfer to Northern Kentucky University (with their much cheaper tuition, but much lower academic standards) because until I satisfy this debt, there will be a freeze on my transcripts. Grrrr.

So the plan is work. Work. Work. Work. And save. No more eating out or quick trips for coffee. No more of going to the video store and renting literally piles of movies. No more. Thanks to UC, my summer has turned into nothing more than work and school, school and work. Not that this is a change from previous quarters, but I was hoping to find some time for at least a little bonding with Evan while he is out of school for the summer. Instead I have to be content with just going to work. I did finally speak to someone in the collections department, and she said what the university did to me is ridiculous, and has set me up on a payment plan. 2 payments of $1000. Thank God I have the type of job with the type of pay that I can work about 3 extra shifts to make $1000. Well, maybe 4 or 5 if consider how my dear Uncle Sam rapes my overtime pay. I've already made a start. Instead of being off from Monday through Thursday this week, I have picked up shifts on Monday, Tuesday, and Wednesday. Which has the added benefit of putting me in overtime by the time I get to my scheduled shifts on the weekend. If you consider that The 4th of July is this coming weekend, and that will be holiday pay AND overtime, so double overtime for those 2 nights, I may be able to satisfy the first part of that $2K obligation this coming payday.

Failure

Sometimes I have the autonomy to override a doctor's orders. Sometimes I do not. This weekend was an example of a time when I did not. It was also an example of the concept that just because we can do something to prolong a life doesn't always translate to we should. A lesson in medical futility and ethics. I have been assigned to the MICU for the past 6 days. The sickest patients in the hospital were once again in my care, as is happening even more frequently now.

A patient was admitted on Wednesday night, and by Thursday, it was well-known that there was nothing we could do for him. The name was familiar to all of us, but none of us could place his face. Disease had ravaged his body until there was little with which to work. I am not going into detail about the disease process or any other fact that can be used to identify this patient because I want to protect him as I am legally obligated to. But he was very, very ill. I watched as a parade of specialists for just about every body system in a human organism came and went from his room, speaking with his family.

I'm sorry. There is nothing more we can do.

We will provide him with comfort while he makes this final journey.

We will allow him to die with dignity.

I made sure he had enough oxygen, then went on to other patients of mine. Patients who were not breathing on their own, hooked to my ventilators. Not much time passed before another specialist came to see the patient. The patient, on top of everything else, had a raging infection. Sepsis. He wanted me to suction the patient, something we don't usually do for the dying patient because it is so uncomfortable for them. I asked him to explain why. His follow-up was that we were going to suction him, and then intubate. Within 15 minutes, the family wants to do everything. Put him through the medical gauntlet. The doctor seeing the patient for his infection bypassed the cardiologists, nephrologist, pulmonologists, neurologist, and oncologist. Told the family we could fix him.

My experiences with family members facing the loss of a loved one have taught me something. You must be very careful when you walk into the room of a dying patient. Because any tiny word you utter can be misconstrued as hope. Hope where there is none. And they grab onto to that like a life preserver, and hang on to it. To the layperson, this would seem like a gift to them. Instead it makes it worse. The patient passes away anyhow, after they have thought it was not going to happen. From the minute we know that death is looming, our care shifts from the patient to the ones left to live. Every action becomes about them. Making it easier for them. Never more difficult. The have enough difficulty to face.

We failed that family. We didn't do what we should have done for the patient.

We intubated. I hooked him up to the machine that would breathe for him. I stood at the bedside and cleared mucus from his chin and smoothed down his hair while the ventilator hissed and puffed behind me. In that instant, I realized who he was. One of our regulars, I would always save his breathing treatment for last because we would always end up talking about his military service and kids. Through all of his admissions, he never forgot that my son's name is Evan. He would always light up and ask me if my Evan was still driving me crazy. He always called me his "Breathing Angel" because he said I always seemed to show up in the same instant he was thinking about calling for a PRN treatment. I tried on several occasions to explain to him that it was probably due to the fact that he was due for his medication and less about me. "In fact," I would tell him, "I'm actually really mean in real life." He would always giggle and shake his head, telling me he couldn't believe it.

I almost didn't recognize him through all of the tubes and lines.

Within 5 minutes of intubating him, he tried to go into cardiac arrest. We brought him back. I heard his ribs crack during CPR.

By the time I had reported for the next day, he was on continuous dialysis. We had given him the maximum amout of medication allowed to maintain his blood pressure. Dopamine. Levophed. Vasopressin. I was no longer able to maintain any sort of oxygen saturation on him. We had to insert an arterial line in his femoral artery, in his groin. His body temperatre was 88 degrees. We had him wrapped in heated blankets and a warming system so that only his face was visible. He had a rectal tube inserted that was draining blood. 10 IV pumps going. About the only drug category we didn't have covered was sedation. Through all of it, he didn't need any.

The family still was clinging to the hope that we could fix him. Despite the fact that we told them repeatedly that it was gettting worse. They held fast to that life preserver. I left my shift praying for his death.

By the time I reported for my shift the next day, he had died on his own. It took 6 nurses and me to remove all of the lines and tubes. His body released every fluid in it. There was a piece of tissue that I assumed to be a part of his trachea that came out when I removed the endotracheal tube.

I didn't cry. Instead I hated my job. I was upset that I didn't put my foot down for him and advocate for him. I realize that even if I had, and refused to participate, they would have just called another of the therapists. This was one of those that I could not override.

I still feel like I failed my patient. I wasn't his Breathing Angel anymore.

Whatever

Hate My Life @ Yahoo! Video

Ummmm. Do you notice a trend? I post videos when I am too busy to write or when I have nothing to say.

Yesterday, at the gas station, as I was walking in to pay for my gas, some guy asked me if I would give him money for cigarettes. Not food. Not gas. Cigarettes! Beggars have gotten ballsy!

In the meantime, finals week is rapidly approaching, and because of the $1K electric bill, I have been working weeknights in addition to my weekend shifts. I don't think the black circles will disappear from under my eyes any time soon. I have literally been going about 48 hours between chances for even a little sleep. Go to school all day, then head straight into work, then get finished with work and go straight to school. I'm exhausted. And everyone says "Just wait until med school!" Seriously? By then, I will not be working 70-80 hours per week in addition to a full-time class schedule. I do not plan to do this to myself then. So med school? Not scared.

Swine Flu B.S.

(* I found this pic on the internet. LOL)

I have had the sniffles and a sore throat for the past couple of days. I am obviously not feeling well, and as I cruise the halls of the the hospital while working, and encounter other healthcare professionals, I have heard nothing but the following: "You don't have the pig flu, do you?"

No. I do not have swine flu. Stop asking me. But I do have a patient whom we suspect does, and I will go no further than that. But let's talk about the pig flu, shall we? It has, thus far, caused no abnormal symptoms, save for the standard flu symptoms. And while the global death rate for influenza of which we are accustomed climbs into the thousands and thousands, at last check, swine flu has only caused a couple of hundred deaths worldwide. So why are we freaking out?

Well, this marks one of the first instances where we can catch an illness that has morphed from animals. (Not the first. Remember avian flu???) But everyone is in a dither about this. Everywhere I go on campus, there are signs posted on doors, windows, walls, about prevention of the swine flu. Seriously. Even my husband is not exempt. I mentioned that we had a suspected case, and he practically wanted to red-bag my clothes and burn them when I got home. I wanted them off as soon as possible just because I was dealing with influenza, and I have a child and husband at home who have not had the wealth of vaccines I have had due to my position in healthcare.

Maybe it is just me. I don't get worked up about MRSA or TB or influenza. I use precautions when dealing with these patients because I want to protect my other patients and my family by not becoming a vessel of illness. But most of this stuff is just common sense. Wash your hands, especially after touching something that a gazillion others touch, like door knobs, light switches...Make your loved ones and friends throw away their dirty tissues instead of laying them around. Sneeze or cough into a sleeve of tissue, then wash your hands anyway. Stay away from hospitals if you can. We try really hard, but hospitals are full of sick people. Those of us in their employ have someone in infection control to ensure we are protected. We try to protect visitors and patients too, but some people just do not listen. (Case in point: the suspected TB patient who SNUCK out of her room for a smoke!) Do not, by any means, be the idiot who has your 2 year old cruising the halls barefooted. No doubt, they are treading on c. diff and MRSA and VRSA and streptococci and anything else you can think of that settles to the floor of a busy ER.

So why am I not scared, other than reasons I just mentioned? There is not one single part of me that does not believe that I do not have MRSA all over me. If I were to get sick enough that they were to test me, I am sure I am completely colonized with it. I have had my flu vaccine, and I wash my hands before entering a room and before leaving. (That's a lot, for those of you who do not realize what it is that I do.) And in between those frequent washes, I sanitize. When someone is going to be coughing in my face, which is pretty much all of the time, I wear a mask. If I am going to get something on me, I wear a gown. When I get something on me when it was not anticipated, I bag my laundry, and either turn it in to the disinfecting gurus at the hospital or I wash it seperately with peroxide, then wash it again, by itself. And I wear gloves pretty much all of the time. My son and husband do not come to visit me at work. Common Sense, really. All of it.

Quit freaking out over swine flu. Because each year, as we get vaccines for new stuff, there will be other new stuff to emerge from which we are not protected. Viruses and bacteria are a clever sort. The morph and evolve too. Are we going to panic about every single one of them? Really? Calm down, says the Respiratory Therapist soon to have a degree in Molecular Biology. It'll really be okay.

Tales from Behind The Mist....Of Albuterol

From the "Are You Serious?!" File....

Some true stories from work this weekend.

Phone rings and it is Nurse X: "Andrea, can you come and give the patient in room XXX a breathing treatment?"

Me: "Sure. Whats going on with the patient?"

Nurse X: "I don't know. He wants a Coke. Can you just give him a treatment so he will shut up about the Coke?"


Phone rings and it is Nurse Y: "Andrea, my patient's sat is 85 on 2 liters. Can you come see him?"

Me: "Did you turn up his oxygen?"

Nurse Y: "Yep. To 5 liters." (sounding very proud of herself)

Me: "What's his sat on 5 liters?"

Nurse Y: "I don't know. I left to call you."

Me: "Well, I am in the ER with a full arrest. Go and see what his sat is, and if it still low, put him on a venturi mask at 50% and 15 liters, and I will be there as soon as I can. Do you know how to do that?"

5 minutes later the phone rings. Nurse Y again: "Andrea, I think I broke the venturi mask."

Me: "Get another one and try again. I am still bagging this patient in the ER."

2 minutes later, Nurse Y, again.: "I don't think 50% is going to fix this. We need to go up on his oxygen, not down."

A few minutes later, I head to the room. The patient's sat was 100%. His heartrate was 85. I put him back on his 2 liters and went back to the critically ill patient I left in the ER to deal with this.


Later that night, a full arrest in the ER. We are intubating the patient and I have the nurse behind me at the crash cart hand me an en-tidal CO2 detector to verify proper tube placement.

Doctor X: "That won't work on this patient."
Me: "Well it is habit, so just humor me."
After a few breaths, we get the color change that shows the tube is indeed in the lungs and not the esophagus.
Me: "See, it worked."

After the code, Doctor X comes up to me, and in a gentle voice asks me if I understood why it would not work for that patient.
Me: "Well, it did work. Plus, It is an ACLS standard that tube placement be verified with an end-tidal CO2 detector, and therefore it is the policy of this hospital that we use it after an intubation."

Doctor X: "Well ACLS is wrong. I'm going to write them about that."


Seriously, people. Seriously.

Being Seen

I have had the most interesting weekend at work.

For the first two shifts of the weekend I had the ER, along with some general med-surg floors. I had to confront death head-on for a couple of patients. I lost one battle and am still in the process of losing another.

A 75-year-old man comes in as a full cardiopulmonary arrest. We are doing CPR, and they let the family back. I hate that. Hate it. I have to remain detached and professional to do my job effectively. But this little old lady comes limping back with her family, as we are doing CPR on her husband of over 50 years. They have had this life together, and I feel like we are taking that away from her when there is nothing we can do to save the man. As I watch her cry, I am finding it hard not to cry. The doctor calls time of death and I help her limp to the bedside, where she gives him a kiss on the cheek and crumbles with grief.

The next night, another full arrest comes in. That is what these patient's are to us. The full arrest in bed 18 or 8 or wherever they land. Not a name. She comes in already intubated, so the task of ventilating her falls to me. I am tweaking the vent to find a way to ventilate her that works best with her natural patterns of ventilation. I have my back turned to the door, turning knobs on the vent. I turn around for some unknown reason and see this sweet guy from housekeeping there behind me. In that instant I assume he is at work until my eyes take in his street clothes. He looks at me with these wide eyes, and I just know. I ask him if it is his mom, and he just nods. He stays in the room while we do all sorts of medical procedures to the woman. She is nude from the waist up for an EKG, and all I could think of was my relationship with my son, so I reach over and cover her breasts with a sheet. Later I go down to the smoking area for a much needed break for coffee and a Marlboro Light. He is down there smoking too. Before this, he and I would joke about college football. He would tease me about my hatred of Florida. He was always quick to offer a smile. Before that, I don't think either of us were very aware of what the other does in the hospital, other than these huge badges that go along with our picture badge that is designed to quickly reveal to patients just who we are. Mine says "Respiratory Therapist" in bright green. His says "housekeeping" in pale blue. But that night, in his grief, he saw firsthand what it is that I do. Never again in his eyes will I be the joking girl who loves Buckeye football.
We are sitting there talking. Once again, we are just two people down in the smoking area. There is no whoosh of a ventilator in the background or a beep of a monitor. He looks at me and gulps down tears as he thanks me for all of the hard work I do, not only for his mom, but for all of the other patients I see on a nightly basis. I get choked up by that. Because every night, I whisk in the room in response to a call that someone somewhere in the hospital has stopped breathing. I do my job and slip quietly away unnoticed by the patients' loved ones. I stay under the radar. They will never remember my name like they will the nurse who takes care of their loved ones. Or the doctor charged with their care. They don't know that I am the girl who stands over their family member, with my back breaking and the hot exam lights forming beads of sweat on my brow, breathing for them when they cannot. I am fine with that. I know what I do, and somewhere inside of me, despite self-criticism, I know I am good at my job. That has always been enough for me. It is okay to be the unseen. But that night, I was seen. And the reality of what it is that I do for a living settled with a big thunk somewhere inside of my soul. I see hundreds of patients nightly. I never remember names-- only faces. In that instant, a myriad of faces come back to me. I worry myself daily if I have been a success at the tasks I have undertaken. Did I do well on Exam X at school? Will I get into medical school? Does my time away from home to pursue these goals I have set for myself do harm to my husband and son? Am I truly making a contribution to this world in which we live? In that instant, the housekeeper from the hospital gave me my self-worth on a silver platter, showing me that this is who I am. That I have touched lives, even when I didn't realize I was doing anything more than earning money to support my family. And for some reason, at that point in time, my thoughts went to my mother. Is she watching me now? Does she see the hard work I do? Is she proud? What is this work I do really about? My confrontation with the housekeeper had such an impact on me. I am still the nineteen year old girl who lost her mom too soon to lung disease. And I have been battling lung disease ever since. It will not win. I am too tough to allow that to happen. It is like the housekeeper took a large mirror and held it to my face for me to see, saying "Here. Look at her. This woman, who works hard to fight for the lives of others. This woman who is capable and tough and smart, who can do whatever she deems fit in life, who will reach the dream she has set for herself, who is Pauline's daughter and John's wife and Evan's mom. She is you." I need to be thanking him.

2 Less Teeth

I let them do it. I was nervous, and it was a good thing that the sedative works quickly or I would have probably chickened out on this. I looked the surgeon square in the face and asked if he was "prepared for an airway emergency". He gave the nurse the "Do you believe this one" look, to which I responded, "Hey, you know what I do for a living, right?" After that, the last thing I remember is him telling me about the patient he had to trach in the chair. Next thing I know, I am awake and giggling uncontrollably, and the wisdom teeth are gone. Apparently Versed is to blame for the giggles, though I have never seen it have that effect on any of my patients.
Everyone has told me how painful it is to have these boogers removed. I have been pretty sore and not feeling well because I have been taking a low-dose narcotic painkiller. But I have refrained from those for over 24 hours, and now I am feeling the aftermath. But to be honest, after the pain I was having before they were removed, I think this is an improvement. Plus I have the psychological benefit of knowing that I have no more wisdom teeth to cause any problems. All 4 are gone now. I just know that the plan is to work tonight, and I want nothing in my system for that. I have bought a fricken enormous bottle of ibuprofen just for work. I still cannot eat solid foods though. That's okay. The hospital cafeteria has a wealth of frozen yogurts and Jell-O, soups, puddings, etc., to choose from. I'll be a-okay.

Me Blogging about A Pic of Me Blogging

I had the night from Hades last night at work. 13 vents in just one unit, and I had multiple units. Here in a half an hour, I have to get ready to go back. So yep, I look like ass. No makeup, pillow creases on my face. I am dog-tired. I get my butt kicked just about every night at work. But tonight, I know I will. There is just something about the possibility of having an easy night that makes it much easier to go in in the first place. But for some reason, when you know the mountain of work will be insurmountable and there will be just some patients you cannot physically get to because you are so busy, followed by the realization that instead of being off in the morning, it is the start of your school day....Well it is enough to make you want to stay home.
But alas the time has come for my shower to get ready. I have to do my job.

I think I am running out of steam.

Do Not Touch the Feet

Ask any of us in health care and we will tell you that we have had some strange encounters with patients or their family members. I have a favorite...

I was called to the bedside of a very unfortunate patient in his early thirties with a head bleed. The man needed surgical intervention beyond the scope of the tiny rural facility in which I was employed at the time. Air transport had arrived to take him to the nearest trauma center, and I was standing at his head, bagging. I couldn't step away, as I was literally breathing for the guy. We call the wife in to say whatever she needed to say to him as we were pushing the stretcher out to the helo pad. I hate this part. Usually, it makes me tear up. Not this time. It was all I could do to remain professional and not crack. This woman actually walked up to her husband and said the following. "Nothing better happen to you, because you know what will happen, don't you? I'll have you stuffed and sit you in the corner. Taxidermy is cheaper than a funeral!" She proceeded to smack him on the forehead and tell him she would see him when she gets there.

Well, the other night, I had another strange encounter. There was a very young child who had assessments and treatments ordered every 3 hours. When this is the case, I try to be quiet as I walk in the room, hoping I can observe the child and possibly give a treatment without ever having to wake the family or the kid. This little boy's oximeter probe had fallen off of his finger, and was sort of stretched out. i figured I would put the probe on his big toe, and started to do so...

All hell unleashed. The dad started screaming at me, "Dud, what the F### are you doing??? Don't touch his F###ing feet, man. Who the F### do you think you are??? Why the F### would you do that???" Those are actual words, without the censorship. Seriously. This is a sample of what I endure at work. Really. For 12 hours a night.

They Said No

I am still sick, of course. Very sick.

Well, we have this policy at work that in the event that someone is called off of work due to overstaffing, you can indicate that you would like to be the one by placing a big red dot by your name on the schedule. It says to the world that, hey, I am a team player and did not call in, but if you are going to send someone home, please let it be me.

I called my supervisor, realizing there was a snowball's chance in Hell that anyone would be called off, to have her red-dot my name. Ha! Hahaha! Let's just say, I got a lecture and am now off of work tonight. As it turns out, several of my coworkers are off from the same thing, one of which has pneumonia. 10 bucks says we all got it from the same patient. "I really don't need you here in that condition." Grrrrrr. While it is very true that I now have an entire day off of work, I hate it. I hate doing this to my coworkers, making them work their arses off to cover for my absence.

In the meantime, I found out something interesting. Each and every day I report to work, I find myself adjusting to the difference between this place and my previous employer. Other employees grumble about the place, but I know better because I have seen firsthand that there is worse out there. Much worse. This place actually takes care of its employees. But here is another difference I discovered: if you are ill for whatever reason, and it is something that is deemed contagious by your doctor, so long as they document it in writing and you report it to employee health, the absence cannot count against you. Fabulous. I only miss work when I am physically unable to work due to illness. I missed a couple months back because I had this horrendous stomach virus, for example, and was unable to get out of bed.

I have made a doctor's appointment for this afternoon. I really hope I have nothing but the flu. But I cannot breathe. I see a chest x-ray in my future.

Flu Happens

Forget Chemistry and Biology, work and family and everything else that is going on.
I. Am. Sick.
I have no idea how I am going to manage to be successful at work tomorrow night (or at any other task I undertake in the next couple of days).

Right now, I just know that I cannot call in sick. One coworker is on FMLA because his wife just had a baby. Another took a leave of absence, and I am not sure why, but I am sure I will find out when I report for my shift tomorrow night.

It all started with this benign tickle in my throat. Which made me cough just a little bit, but hey, no big deal, right? I popped Halls Defense tabs like they were going out of style, telling everyone that I cannot get sick. Between school and work, the world will stop turning if I am ill. But then it happened. I was cuddling with John on the living room floor, all snuggled in a blanket, watching a movie, when I started to cough really hard. I coughed so hard I urrrrrppped. Gross. And John, God how I love him, helped me clean myself up and helped me get tucked in on the sofa for the night. I remember waking up this morning, freezing despite the big comforter wrapped around me. The rest of today has passed in a blur of periods of awake and sleep. I would be freezing, and he would wrap me in such a weight of blankets that I should not have been able to breathe. I would wake a few hours later, drenched in sweat, and toss off the blankets. All of this only to repeat the ritual an hour later. The monotony was broken up by him bringing me a dose of Robitussin every 4 hours.

The period of time I would have spent in chemistry recitation came and went. Lecture came and went. In a fit of wakefulness, I ended up emailing my professor this afternoon to let him know where I was today. We have these little cards, worth only two points each, that we turn in during recitation each week. No big deal, but they add up to be a full quiz grade at the end of the quarter. In his response, he told me we would talk when I return on Tuesday. I am sincerely hoping he will cut me some slack on this one.

Other than all of this, my body is racked with aches and chills, and I truly think I have the flu. My mind flashes back to a time earlier in the week when I saw a headline that the flu is showing some rather resistant strains this year. "That's interesting", I thought, as I went on about my day. Now I am left to ponder that in conjunction with the fact that I got a flu vaccine earlier in the season from work. In fact. they pretty much made me, in that if I did not, I had to fill out this big waiver for the hospital, which in turn is reported to employee health, etc. In other words, just take the damned shot already, and thus I did.

Oh, the irony!

So now I am sitting here, typing this in a haze. I know I should use the time to study, being that I slept all day. I am having a hard time being productive, and am starting to feel hot again, wondering if I am about to break another fever. Blah!

Nothing Changes But the Seasons

Haha!

My first round of exams has been completed for the quarter.
Biology: Big-Time A, even though most in the class failed it. I am officially the curve-breaker once again.
Chemistry: Hmmmf! I failed the damned thing. I am Andrea, dammit! Yet I failed a chem exam. I shouldn't be too hard on myself. Everyone else did as well. Just when I was about to drop the course, I was reassured when I was told that my prof is notorious for "breaking you" in the beginning. The exam was terrible, really. I literally started to tear up a bit in the last part of it. And when I saw my grade? I needed some Ativan. Seriously. The good news is, since everyone did terribly, he has given us the exam back and we are to prepare a "Self-Assessment" to be submitted in the form of short essays for each missed question, to include what the hell we were thinking that caused us to give the wrong answer, and what the correct answer is with the logic that explains why it is the corrct answer. Lots of work. My rough draft of mine is already completed. I just have to neaten it up a bit and submit it, even though it isn't due until the 17th. I guess I just got excited about the idea of earning back my points. It has been my priority over the past couple of days.
Calculus: I am dropping this course tomorrow morning. It is just too difficult for me to stay awake after my shifts to go to this little 50 minute class. I plan to retake it with the same professor next quarter, if I can.

I am still doing th standard 3 twelve-hour shifts on the weekends. Blah. At least tonight is my Friday.

Respiratory Distress

...Is in the eye of the beholder. Seriously.
I get a call from a nurse. We will call her RN. I like RN. RN and I have never had a problem. She is telling me that my patient is in respiratory distress and would like a PRN treatment. I respond.

RN is sitting at a desk when I get to the unit of the hospital. My first thought is : "If the patient is in such distress, why is she not at the bedside?" Realizing that crazier things have happened, I go to the patient's room. The door is closed. I knock lightly, then enter. The room is dark, but in the glow of the bathroom light, I can see it. The patient and her husband are both sound asleep. I tip-toe to the bedside and see that respirations are normal. Her breath sounds are clear, save for a few scattered crackles in the bases, which does not surprise me, considering the patient's diagnosis. I tiptoe out of the room, and as I pass the desk where RN is sitting, I give her that look and let her know that the patient is sleeping like a baby. I go back to my laundry list of tasks to complete.

30 minutes pass.
My phone rings again.

RN: "Andrea, she woke up and is breathing so badly that she is sobbing."
Me: "Sobbing????" (This isn't the usual presentation of respiratory distress.)
RN: "Yes, she says it hurts so bad...."
Me: "Wait a minute. Is pain her problem?"
RN: "Yep. She says it hurts in her side."
Me: "You know, albuterol won't fix that."
RN: "Well then, she's short of breath."

I go to the room. Again, RN is sitting at the desk and the patient's door is closed. I enter to find her awake this time. I ask what the problem is and she says that it hurts to breath. I ask her to describe her pain, and she clutches at the right lower rib cage, explaining that it hurts to take a deep breath. I observe her and notice her wincing with each breath. I ask her if she is short of breath. "NoNotReallyItJustHurtsWhenITakeADeepBreathCanPneumoniaDoThatIDidn'tKnowPneumoniaCouldDoThat."
Long run-on sentences. Normal respiratory pattern (rate and depth). SPO2 is 98% on 1 liter of O2. Heart rate is 86. Breath sounds completely clear. I know that nothing I can do is going to help her. She needs her pain meds, which come from RN. I explain to her that we can try the treatment, but that it really won't help if her problem is pain. She is too vague, so I give the med. After the treatment, she insists she is cured. There is no more pain. (!!!!!) I am convinced she needs a psych consult. I leave the floor, but not before letting RN know that while I did treat the patient, she was not in respiratory distress. That while I would love to run around the hospital appeasing patients and nurses all night, I truly have patients who need me.

As I am walking out, I think I should stop and see the patient on Q4 treatments. She is due for the next one in 15 minutes. I walk in her room. She is sound asleep. I gently wake her and let her know it is time for her treatment. She blatantly tells me she doesn't want it, doesn't need it, and rolls over and goes back to sleep. I chart the refusal and go on about my business.

45 minutes pass. It's RN again.

RN: "Andrea, our patient in room xxxx is feeling short of breath and would like a breathing treatment."
Me: "Seriously???? I was just in there less than an hour ago and woke her up. She refused. What changed?"
RN: "She refused??? (soft giggle) Well she wants one now, says she is short of breath. She just got back from being downstairs smoking."
Me: "Let me get this straight: she wouldn't let me treat her 45 minutes ago, but then went down and smoked and wants me to make a trip up there to treat her because she is short of breath after her trip to the smoking area?"
RN: "Yep (louder giggle now)." Shall I tell her she's on your 'list'?"
Me: "Yes, thank you."

"Respiratory distress" and "dyspnea" and "shortness of breath" are all subjective terms that are used too loosely in a hospital at night. They know I have to respond to a call that uses those words. I trust that the nurses have used their assessment skills, that they know I am busy, and have filtered through some of the BS. This is not always the case. I got calls like these all night last night. All 12 hours. A lot of them weren't even from my assigned units of the hospital. They were from other nurses who didn't feel like they got a quick enough response from their therapist and started dialing random respiratory extensions until they get me. In a respiratory eutopia, we would have the staff to run around and do this random crap. At my place of employment, we do not. At 11 PM, the respiratory staff cuts down from 8 therapists and/or techs to about 4 therapists (no techs at night because we have to be able to handle it when we are called). I am one of the lucky 4. And if you divide the hospital into 4 equal sets of work units, you wind up with therapists who have anywhere from 5 to 8 units of the hospital. I had the entire 2nd floor of the hospital last night, plus NICU and pediatrics, for a grand total of 9 units of the hospital. I do not have time for bullsh*t calls like this. And with assignments like this, if there is a code at night, all of us respond because you are never assumed to be able to go to a code on your own floor. I have been known to have simultaneous codes going on at multiple units to which I was assigned. So in the middle of all of this, I had to respond to a code, which resulted in my brand new shoes getting doused with so much vomit that it soaked through to my socks. In the middle of it all, I have to call the supply people and have them deliver to me a fresh set of scrubs, shoe covers and a jug of hydrogen peroxide. I got the puke out of my shoe, but only by pouring the entire bottle inside and outside of it, then having my toes squish around in the peroxide-soaked shoe for the remaining 5 hours of my shift. Fun.

God, I hate being a "floor whore". Send me back to the ICUs or the ER. Please!

The Word of the Day: Juggling

Busy, busy, busy me.

John and I have this little thing going. There will be a show coming on the tv at night that I want to see. I will be posted up in my office, studying, and he will let me know when it is coming on. He then helps me transfer my pile of books and notebooks into the living room, where I will lay on the floor while he rubs my back and I study while absorbing the show through osmosis. Ivariably, after about an hour, I will tell him that I need a little nap, and will instruct him to wake me after about one hour of sleep. No matter what I say or how much I gruble or what name I call you, WAKE ME UP! I have x, y, and z to get accomplished because this is my only night to do them. DO NOT let me sleep all night. The problem is that once I am asleep, being as sleep-deprived and busy as I am, he cannot get me to wake up. It is like I go into a coma. After several nights of this same thing, he has finally wisened up a bit, and when I say "let me go to sleep for an hour", he responds with "Hell NO!".

The moral of the story is that I have this laundry list of tasks that must be completed and since I snoozed all of those nights, I have to get them done NOW.
But...

Today is my Monday. I work 12's the next three nights. Monday night I have biology and its lab. I literally have to make use of every free hour I have to get this crap done.

As soon as I log off, I plan to study until 2:30-ish. Then I plan to go to sleep for a couple of hours so I can function at work all night. If I wake up by 1:00 Saturday and Sunday, I can get a few more hours in each of those days. Monday will start with the completion of my night at work, followed by calculus and a meeting with my Pre-med advisor. If I hustle, I can get a few more hours in there before I have to head to Biology. If I stay up till 1:ooAM Monday night (normally I would say 2 or 3, but since I would have worked the night before and not slept, I am being nice to myself), I can get more done then. Thank God that my Chem lab is cancelled Tuesday morning. I don't have class until 2 PM as a result, and if I take all of my stuff to campus with a packed lunch, leaving the house at the normal time, I can get most everything else done with no distractions. Or interruptions. Or temptations.

This is what I mean by "juggling".

So I am left with this question for myself: Do I really want to be a doctor? Is it worth it to torture myself like this for many years to come?

The answer, after some thought: a resounding, unwaivering, Earth-shattering YES!

Tonight was #7

And the ER is attempting to go on diversion. In other words: Crazy as all Hell!
I actually was scheduled to be off at 11Pm tonight. With codes in the cath lab and patients in crisis all over the place, 2 out of the 4 ER's in Northern Kentucky already on diversion, and ours attempting to, I felt guilty leaving my coworkers in that mess. The problem is that I have literally worked 70 hours in 7 days. In over a week, I have not had a single day at home with my family, including Christmas Eve, Christmas Day, and my anniversary. I am also scheduled for two more nights before I have any time off, and even then, it is only one day. I really needed to leave, so I did all I could to make it easier for the person relieving me of the units of the hospital to which I was assigned. On top of that, it has been a crazy night: patients falling, going MIA, ripping out picc lines. I am tired deep down in my bones. So now I am home. I miss John and Evan.

Day 5 or Day 6??????

Hell, I don't know anymore. I know I am never ever signing up for this many shifts in a row again. I realize that as I hit med school and a ghastly residency I may be forced to do this. But for now, I do not have to. So I am here, at work, sitting at the computer in my little cubby of the ER, waiting for my pager to go insane and debating on whether to go to the gift shop and buy the latest Cosmo or if I should be doing some organizational tasks to prepare myself for the pre-Med Hell that begins one week from Monday. Uh-oh....Pager went off.....Inhaler instruction with a spacer.

So Anyhow...Class starts January 5th. Somehow I managed to end up in a little Chemistry marathon on Tuesdays and Thursdays, between the lecture, lab, and recitation. Monday and Wednesday are reserved for Calculus, which I have not touched since I was a senior in high school, circa 1995. Monday and Wednesday nights are my biology nights, which should be easy for me. Yes, I actually think biology is fun. For me, the Krebs cycle is as much fun as shopping. I threw a history course in there somewhere, but I forget where. I knew UC would expect me to take something other than my science courses. They actually expect me to be well-rounded. Ha!

How am I going to do this with work? Good question! It's really too bad that I do not work at the other campus of this hospital. The RT's there maily just sit, read, play on the computer, watch movies in-between doing an occassional EKG or nebulizer treatment. They rarely touch a critical care patient because those patients are all sent to us here. There was actually even one situation where an ambulance picked up a patient who went down in their ER parking lot and brought the patient here instead of taking them there first. My point is that there, I would have alll of the time in the world to study. But the clencher is that I would be bored to tears and any critical care skills I have would go completely soft. Plus, here, I rub elbows with some individuals who could potentially write some very impressive letters of recommendations here in a year or so. In other words, I'll keep my job.

Don't Watch

Yep, I stole that pic from the internet. But notice the lovely PB 840 Ventilator in the lower left corner??? By far my fave!

Here is the deal, peeps. We do some things that are uncomfortable for a patient when in an ICU. The list is numerous: chest tubes and a-lines and don't forget intubation. A tube made of polyvinylchloride is not a pleasant thing to have jammed into your airway. But we do it out of necessity. Not rosey and cute. But required. Then occasionally we have the patient who is having trouble breathing and we try to intervene on their behalf to actually avoid intubation. Whatever unpleasantness I could be up to is nothing compared to days of mechanical ventilation, I assure you. What am I getting at? Well here it is:

I know the patient I am taking care of may be your sweet mother. I completely understand that. I had a mother once before. I know you do not want to leave her side. Your presence at her bedside 24/7 is as much your way of ensuring we are giving her adequate attention as it is for tou to assure her with your presence. But when I come into an intensive care room, it is a sign that sweet Mom is just not breathing so well on her own. She needs some sort of help, whether that be in the form of aerosolized meds or oxygen, bronchial hygiene or mechanical ventilation. But please know that I am good at my job, even if that job is not all sunshine.

So you are at Mom's side. Great! But when I tell you I am about to do something unpleasant and encourage you to leave the room, please follow my advice. The most recent situation was the nasotracheal suctioning of an elderly lady unable to speak, and unable to adequately clear her airway with cough. DO NOT insist on watching me thread a catheter up her nostril, through the pharynx and into her trachea. She is not going to like it. She will cough and gag, and naturally try to fight me, at which point I will have to firmly insist she stop. I need to do this. I do not want the process to take so long that she becomes hypoxic or starts to brady down. That would be bad ju-ju. What I can say is that, while unpleasant, she will feel better when I am finished and have removed the nastiness from her. She may hate me, but she will feel better.

Please do not watch me, then get angry because I upset dear Mom. I am not concerned with Mom being upset with me at all. My job isn't to have tea with her or to convince her that I am worthy of her adoration. My job is to ensure that her respiratory function is intact. Making her mad is just a side effect.

If you can't handle the heat, stay out of the kitchen? More like if you cannot handle the unpleasantness, stay out of the ICU (other than for standard visiting hours, of course.)

Seriously? Not the ER?

I knew it. Just knew it. I am at work the other night, working with S (name withheld to protect the innocent), and he laughs and tells me that every night he is working, I am The ER Therapist. Fine by me. I really do, though I gripe about it, love the ER. That is the only place in the hospital where I actually get to see my patients, use my full assessment skills (yes, I have those), and actually, at some point, come across everything within my scope of practice. The part I do not like about being assigned to the ER for a shift comes in the middle of the night. From 2100-2300, you have just the ER. But at 2300, all of the 1100-2300 people leave and the hospital's arsenal of RT's whittles down from 7 or 8 to about 4. Your assignment changes and you usually, on average, have about 4 other units of the hospital along with the ER. This can be okay, on nights that are not so busy. But during Respiratory Season (Haha! November through March when flu/ RSV hits!) this is not the case. You could be clear across the hospital and be paged to the ER to meet a full arrest. You have to break out in a run to get there in time. ER patients always come first. This may be to the dismay of a nurse on a med-surg floor who thinks her patient is your only patient, but is still the case nonetheless. I am always the ER therapist. It's fine. They know me down there, and I like to think that they like me.

I was very shocked this past week. I worked 6 12's in a row, only to find that I was not assigned to the ER for a single one of them. For the past 3 work nights, I had the SICU and Cardiac Surgery Recovery (CSR) Unit. I would run into people from the ER as I made my way around the building, and they actually had thought I had taken a vacation because they had not seen my face around. Ha! No asthmatic kids. No croup or RSV. My patients were intubated and silent, other than the occasional vent alarm or monitor beep. It was actually kind of nice.