16 posts tagged “hospital”
Interesting tidbit, but did you know that if your loved one dies in a hospital you don't need to sign the release of remains off to a funeral home? You can take the body home with you if you like, instead.
My unit (in comparison to the previous one I worked in at a smaller hospital) receives a massive amount of post-arrest patients. The difference with our service is that our unit is probably the one most familiar with initiating what's called the hypothermia protocol.
The hypothermia protocol is a treatment plan that's initiated after someone has been resuscitated from an 'arrest state' (induced by either ventricular fibrillation, ventricular tachycardia, or pulseless electrical activity). During hypothermia protocol, a patient is chilled (down to 32 degrees celsius) for a period of 24 hours and then slowly rewarmed back to a normothermic body temperature. The reasoning behind hypothermia protocol is that if you can chill a patient (whose body has just sustained a large amount of damage and is in a 'hypermetabolic' state) down, you can slow the rate at which the cells are being destroyed and minimize damage to the body and, in theory, preserve some of it's function. All of this winds down to hypothesizing that patients who have been through hypothermia and rewarming have better outcomes than patients who receive no such treatment at all (if they didn't -- why would we bother going through the therapy at all?).
Of course there are also other factors that need to be taken into account before saying that the survivability is greater after hypothermia... Co-morbidities like shock states (cardiogenic, septic, etc.), disseminated intravascular coagulation (DIC), previous damage from other heart attacks/arrests also play into how good of a chance a person is going to have in surviving the arrest itself in addition to how well they will recover from the hypothermia therapy.
Lately, perhaps because we're in the midst of a hot summer, the ICU acuity at our medical center has been through the roof with patients requiring the hypothermia therapy. I'm interested in knowing how many medical centers actually implement a supportive therapy of this type and whether it improves their mortality rates or not.
So lately I've been the queen of the flexi-seal fecal management device -- I've been putting these bad boys in left and right. And I'm wondering how many other nurses out there have used it.
We use it quite frequently in our ICU setting because of the amount of curry-poop-inducing drugs that we give, but I find that sometimes if it isn't done right it induces more work than it needs to. Usually most of the trouble is caused by too little inflation of the balloon that holds the device in place in the rectum.
For lay people, basically the device is placed much like a foley catheter which is a tube inserted in your 'pee-pee' (urethra) that drains liquid in an orifice, by gravity, into a collecting bag positioned below the patient. In the case of the Flexi-seal system however, you're inflating (instead of a small balloon) a small stretchy liquid donut that inflates to expand in the rectal portion of someone's sigmoid colon. The easiest way I've found to get the device in is usually in the sidelying position (or if you're short on help and/or the patient is too grossly heavy -- with one leg bent up at the knee). Also, since I've had to put this device in more frequently than I've wanted to these days, with patients that are greater than 300lbs you can place the bed in Trendelenburg positioning to facilitate movement of their tissue "backwards" down the bed making it a little easier for you to spread their cheeks apart and place the device (this also works with foleys for large women).
With that, you just lube up your donut and maybe an inch of the tubing and with one finger gently slide it in until it's pretty much a finger length in and inflate the balloon with your 45mL of water. Usually the remaining stool sitting in the rectum below where the balloon is placed will ooze out and you won't have anything left to clean up after it's all cleared out.
This is a tube that's not to be used with formed stool (like the kind you can craft a pot out of), but instead with loose formed (which apparently is what the irrigation port is for on the tubing -- but honestly if they can poop something out that's that hard the damn device needs to come out anyway) stools or diarrhea/curry/watery stools. There's a medication we give often that lowers people's potassium called Kayexelate which acts by binding to the potassium from one's intestine and excreting it via powerful diarrhea. I find that the Kayexelate/lactulose/miralax diarrhea is the kind that passes best through the device and down into the collection.
What I've encountered is that during repositioning the tube either gets pulled downward or the donut gets deflated and people aren't reinflating it or repositioning the device when it happens. Sometimes too, you might start to get formed stool (when the diarrhea is tapering off) and you just need to irrigate the tube via the irrigation port near the inflation port for the rectal balloon.
Anyway, this post was just kind of a helpful hint kind of post for all the poop-scooping nurses out there (for better instructions you should see the package insert). Hope your life is a little easier!
Lately, I've been on a serious binge to start saving for graduate school and finding scholarships/funding for schools that I'd like to attend overseas, but so far the search has yielded few results.
I've finally decided after changing my mind time and time again, that when I go to graduate school in a few years I'd like some type of management related degree like an MBA or nursing management. While I enjoy bedside practice, I don't think that it's something I really want to do for the rest of my life, but I'd still like to move up in the nursing world in other ways. Maybe it's my mom's influence in me, but somehow crunching the numbers behind an intensive care unit interests me more than intubating and suspending animation on someone in an operating room as a nurse anesthestist.
Part of the thing that scares me about graduate school is that I'll be going alone. Matt, who is my second nearest and dearest (and whom I've toughed out most of my college years with), is applying for anesthesia school soon and depending on how things go with him, we'll be parting ways to endeavor on our own separate nursing journeys. The scariest part isn't the actual separation itself -- but the fact that I'm losing the support of a good friend that could relate to the nursing experiences I was going through.
Nursing school hadn't seemed so intimidating at the start. To be honest, I didn't really want to be there and felt a certain snobbery against the other nursing students along the lines of, "Ugh, damn I can't believe I dropped mechanical engineering for this crap. I just want to go to med school; I bet these girls are nothing but ditzes." I think after a few years of sobering nursing experiences and realizing that the program itself (one of the top 50 in the United States) was not as easy as once expected, I started to take it more seriously. It was at that point that I also realized I didn't want to lose what I had worked for years to achieve -- when the classes got tougher, I started to see that my intelligence alone wasn't going to get me through university, but that it was going to need harder work as well.
I can't tell you how many times I cried from sheer frustration during my third year of undergrad. In retrospect, there aren't many memories from that period of time that are good ones. It so happened that two of my other roommates during that time were also having trouble with school so I had people I could relate and commiserate with. Matt was always balancing nursing school with his paramedic classes, two jobs, and volunteering -- while he couldn't really 'commiserate' with my particular situation, he always offered a shoulder to lean on about all of it. After several scares (with psychiatric/mental health, and pediatric nursing classes), I made it out of my junior year barely alive and wondering whether I wanted to be a nurse at all. The negative academic experiences I'd had that year really made me question whether I was cut out for medical/graduate school, or even nursing at all. The first positive experience I really had with nursing was getting my first job at the hospital in the intensive care unit that I currently work in now.
It was because of the great guidance of my nurse manager and the nurses on my unit that I even continued nursing school. They showed me an array of experiences from the good to bad and instilled in me an actual love for the practice of nursing and not just the task itself. It's for this reason that I remain so loyal to that unit and part of the reason I cherish it the way I do (as sappy as that sounds).
Someone once said to me that the best care in the hospital isn't given by the nurses and doctors that do their jobs for just "the money", or the satisfaction of helping others -- but the ones who actually do it because they love doing so. I've always thought that this is a good sentiment to have about any occupation regardless of whether it's healthcare related or not.
I'd like to think that in a few years when I leave bedside practice that I'll still love being that kind of nurse and hopefully be starting grad school with the same sort of mindset.
Wack!
The past couple of weeks have been a fun whirlwind, and frankly it's the happiest I've been since my graduation from college.
My new job is a lot harder than the last, but I feel a sense of fulfillment from it that I didn't get while I was still at that other hospital. Right now, I'm caught in a ridiculous schedule involving lots of day shifts, classes, and competencies -- but regardless of how busy I feel, I'm loving all of it. This is a strangely fuzzy and warm comment -- but I love working with everyone on the unit; it's not perfect, but you can definitely tell that everyone works well together despite it.
Being back at this hospital now makes me realize that while it has it's downsides (but really the only thing I can think of is that I pay for parking), the unit itself really works to make its staff happy. One of the attending physicians (there's a new one every two weeks from a set pool of 4/5), even pays for nurses that wish to take the CCRN to take the exam (a ridiculous $325 if you're not an AACN member) out of her personal pocket. Furthermore, the attendings (with their own personal money) even set up a fund so that someone will teach the nurses the material to pass the exam. Unit culture is nice as well -- most of the doctors are addressed by first names (with the exception of the attending physicians -- but that's understandable) and visa versa. I've got a lot of respect for everyone that I work with -- doctors, nurses, unit secretaries, and care partners alike. I count myself blessed to be a part of their team -- and most of all, I don't doubt the care that any of them would provide a patient. If I have heart disease when I get older -- I would have no qualms about them taking care of me. When you can say that about the people you work with, it means a lot.
I feel like I'm struggling a little bit to remember how to do things. It was hard remembering what the codes were to the doors, which forms to fill out, what resources I had... Then there's the constant bustle of taking patients to scans/tests, doctors constantly asking questions, and learning new techniques on nursing procedures. On my first day taking care of patients, I felt a little overwhelmed with trying to do the things I needed to do (I was a little frustrated with myself for forgetting where some things were in the unit), but I still felt good at the end of the day and I'm excited about going back again. It'll take some time to get acclimated, but I'm looking forward to the challenge.
I'm finally really happy again with my career choice. In the few days I've spent at my new old job (oxymoron, isn't it?) I've gotten to remember why I became a nurse in the first place. I feel like a huge burden's sort of been lifted off of my shoulders since re-realizing those things. And, in doing that I realized this:
There are many different kinds of nurses in many, many different areas of practice -- each has their own value, none more important than the other. But personality wise -- there seem to be only two kinds (well three). There are the nurses that see nursing as a job, and the kind that see nursing as a practice. Everyone has to decide for themselves whether they're going to be a nurse that works just for the money -- or whether you're a nurse that works to change the practice of nursing. The third kind of nurse is a combination of the two, and those are the ones that you typically find (thank God) at academic medical centers where the pay isn't always fabulous, but the nurses are. I think part of the dissonance between me and my former job was that I wasn't the kind of nurse that was in it for the money -- had that really been the kind of nurse I wanted to be; I would've moved back to northern Virginia and taken a job in an academic medical center in DC and get paid almost double what I get paid now. What I wanted was a rewarding experience of having made a difference in someone else's life and in the lives of the people that I work with. There is a big unit culture difference between the two, so my advice to a new graduate nurse that's picking their first job is that when you're making your decision, determine first which of the two you are and then pick your job accordingly -- it'll save you a lot of grief.
Had I been given the opportunity to shadow nurses at my first nursing job, I don't think I would've taken it and I probably would've just waited for an opening at my current job to creep up. Of course, hindsight is always 20/20...
Also, I know that a lot of first jobs in nursing are very discouraging to new graduates. I can't tell you how many times I've reconnected with my old classmates and heard their countless sob stories about their first jobs and how horrible their situations are... and all I can say to that is that if you want to keep your wits, and your love of your job -- just move on. Quit the job you're unhappy with (but at least make sure you're doing it for a legitimate reason) and find a new one that suits you more. Job satisfaction in nursing is what keeps nurses nursing. And always remember, though you may be new -- you never deserve to be shit on. Ever. And if some nurse starts complaining to you about how it's not fair that as a new grad you get treated differently, take the wise advice of Erin T. (one of my favorite former co-workers) and say this: "Just because it was crappy for you back then, doesn't mean it needs to the same way for us. This is a new day, suck it up."
In one month, I'll have been a nurse for one year and I can say that the lessons I've learned in this short amount of time have proven to be priceless information for the path that lies before me. And to this year's new grads -- best of luck on the road ahead; may it be full of good learning experiences and satisfaction.
I love my job.
[Edited] PS: I love the fact that a lot of people at my hospital are young, single, and unmarried. And even more so, I like that Sam Reich's young, single, and unmarried doppleganger sits with me during orientation -- he's perhaps funnier than the original gangster himself, but not an interwebnet guru, instead an internal medicine intern.
Girl, boy, game you should have won, job you should have gotten…tell us about one that got away.
Submitted by Phil.
I should've stayed with my first hospital I was with when I was still a student. Had I held out and waited for a nursing job to open at that hospital I wouldn't have had to take that first job that I hated so much. I spent the past 11 months hating nursing thanks the second hospital I worked at. I'm starting a new job back at the first hospital soon and I couldn't be happier to return. Happy days are here again!
PS: I tried to change my blog to Virginia Tech's school colors, but this was the closest I can find. Show a little bit of hokie spirit in memoriam of those that died.
Wednesday night was my last night at my job, and I'm now making my blog public again. :)
Suffice to say, my last night was great. I liked working with most of the night shift nurses and I think I'll miss them a lot when I start the new job.
My advice to people when dictating their advanced directives to medical staff is to accept the option of doing chest compressions. What good is giving chemical resuscitation if you've got no way of circulating the drugs? Sometimes it's better just to go all-or-none with DNR status.
Last night, I ran into a room with a crash cart and a backboard all gung-ho and ready to start some ACLS, when I was stopped with a concerned "no" head movement. The expression on my face was, "You mean we're not going to pump and thump?"
It was understood that this man was definitely not going to survive our life saving efforts regardless of how much support we would give. He was in multisystem organ failure (hepatic, renal, and respiratory), he was old (and I do mean genuinely old -- in your golden years old), and was hooked to so many chemicals that would've been toxic in most anyone with normal kidney function. Still, his family wanted full chemical and pulmonary resuscitation (but like I said, the drugs don't do much if you aren't circulating them). Needless to say, the man died 10 minutes later, after a long two month battle in our ICU.
About an hour later as a nurse was just foreshadowing that her patient just looked like death he suddenly brady-ed and flatlined into asystole. Our jaws dropped as we had just rushed into the room and he was already dead (usually we have at least a FEW seconds). Just as she was calling to let the family know he had died (about a minute in) his heart suddenly began beating again only to flat line. It was slightly spooky and my jaw dropped yet again. He was a full DNR, so we just watched and bid him farewell and good luck on his next journey out of our care and ICU.
Within the next 20 minutes we got both rooms cleaned and both patients device and line-free and ready to be viewed by the families. Ten minutes after both families had left we had finished wrapping up the bodies and bagging them, and about fifteen minutes after the bodies were gone we had another two admissions to fill the spots that were left open from people expiring.
It's scary how quickly life moves on in an ICU. That's my two cents for the day.
PS: On an unrelated note, I found the description on this picture disturbing.
The last place I worked was a large academic medical center in the middle of the city which has both the reputation of being both very good and very bad. It's understandable that everyone will have a different opinion of it, but personally, I loved it there (and is the main reason I'm heading back now). It was in that hospital's different units and corridors that I learned the most valuable nursing lessons -- and where I also gained my love for health care in general. It was also the place that I saw a lot of my "firsts" in nursing.
While I was still a student, I had the opportunity to work in several of the ICUs (and step-down units). My favorite of them was the Coronary/Coronary Medical ICU, my home unit. It was there that I first watched a patient die, and there that I also first watched patients be 'brought back from the dead.' Between there and where I work now, there is a serious difference in the culture (and I don't mean this in a derisive manner) in the way individuals with advanced directives are treated.
The very first patient that I watched die had gone into a full cardiac arrest (asystolic for 20+ minutes) at a nearby prison and was revived en route to our hospital where they underwent a cardiac catheterization to have an intervention. Prior to his arrest, he had an infection in his newly placed dialysis access port, and was stabbed in it causing a massive blood loss. Add to that the delay before intubation and the problems associated with a full arrest and you've got a cocktail that is incompatible with life. On arrival to the unit -- he was septic, had a pH of 6.9, and was coated in blood; the only things keeping him alive (and just barely, at that) were chemical pressors, constant transfusions of blood products, a mechanical ventilator, continuous veno-venous hemodialysis, and several doses of emergency drugs to control irregularities with his heart rhythm. In addition to that, we were seeing a lot of bleeding coming from every one of his orifices -- nose, eyes, ears, penis, rectum. That night, the gastroenterology team on-call came to 'scope' him and were unable to localize the source of his bleeding because of the sheer volume of blood that was just pouring out of him. It was clear however, that this man was a goner -- his belly growing larger by the hour, and his blood pressure and heart rate fading as well. His family was asked to come in that evening to make decisions regarding his medical care, and whether or not to continue to aggressively treat him. It was, with heavy but benevolent hearts, that the family made the choice to allow him to be a DNR (do not resuscitate). They wanted to continue with the medications he was already on, but to let him die without any additional life-prolonging measures like CPR or defibrillation. The nurse that took care of that patient for the rest of the night was swamped with the backlogged charting and medications that needed to continually be given to keep the patient comfortable.
Around 6am, the man slowly passed away into an agonal pulseless electrical rhythm. I watched as his family cried until their faces were red, and they could no longer breathe from the suffocation of the grief. They'd made the right decision -- I couldn't imagine prolonging their misery, or the patient's. The nurse that was assigned to him, asked the resident on-call (Seth) whether he should just unplug the ventilator and let him 'go'. Seth responded with, "he'll go in his own time, you don't need to expedite it any further." At which point the resident looked at me and said, "Don't you ever become that kind of nurse."
It was around the time that I'd first watched that patient fade into death, that my own grandfather's illness began to take over. He was a very sick man in his 90's -- he had been a smoker for an amount of years longer than my own mother's life (she was 55 at the time) and had only quit when my youngest cousin was born. My family, being the kind of people who can't live with guilty consciences chose to keep prolonging his life with this procedure and that; stuffing tubes every which way, until my grandpa could no longer take it and was attempting to remove the tubes himself. My family couldn't live with the idea that they shouldn't do everything they could to keep him alive. The man had esophageal tumors large enough to obstruct his ability to swallow and was receiving tube feedings through a nasogastric tube that was large and uncomfortable. The mental torture of being unable to eat also got to him, and eventually he pulled the tube out himself and attempted to feed his weakening body. He died sometime in the night, sleeping.
This fall, as I took my first critical care course as a nurse, the issue of having an advanced directive was addressed. It was the general belief of the people that took that course, that individuals who had designated themselves as DNRs should not be 'treated.' I was slightly saddened and dismayed that everyone seemed to think that being labeled a DNR meant giving up treatment altogether -- which wasn't what I had so painstakingly learned in the previous hospital setting I was in. I still remember everyone in the classroom staring at me and saying, "what's the point of continuing to treat someone like that?"
Maybe I'm too fond of life, but I take a DNR to mean that in the event of an emergency (and by this I mean anything preciptating asysole), a person would want to just be left to pass away in their own right. There are DNRs in every different shape and form -- and not everyone is like the first patient I saw die. Some are cancer patients that want to live out what life they have left, and even though they have terminal illnesses still undergo some form of treatment to give them a bearable quality of life. Others are healthy individuals that just don't want to go 'out' in such a manner as a coding patient does -- does that mean that you wouldn't continue to treat their other illnesses if they were (and I quote) "...just a DNR anyway,"?
Perhaps I'm too passionate about saving lives, but the attitude of those nurses disgusted me to the core. I understand the need for DNRs and the belief of benevolence involved with implementing them (in fact, I myself have my own advanced directives), but I don't think that because of them you should just be given up on altogether. Healthy DNRs walk into a hospital to be treated, and if they didn't want to be they wouldn't have appeared at all -- or would've signed out AMA.
My last statement opens up another can of worms altogether, but my point is that I've slowly realized that most of the nurses I work with are all of the same fabric -- that a DNR meant you 'do not care'. While there were individuals at my old hospital (like the nurse that had the first patient I watch die) that had pieces of that fabric sewn into them, it was the amalgamation of other nurses and members of the house staff of doctors that taught me that DNR didn't mean a 'death wish.' When I think back to what Seth had said to me, I realized that these nurses I had been so disappointed in were precisely the ones he spoke of.
I don't know what made me think of it today, but I'm both glad and thankful I remembered the philosophy of what he and others had worked to instill in me.
Last week I went to an interview at the old hospital that I used to work at. Seeing everyone smiling and greeting me with hugs was great. It made me feel nostalgic for the old days when I was a part of their staff too.
The interview started out with laughs and giggles reminiscing over differences between the health system I work for now (that both the interviewers had also worked in) and had progressed into a more serious difficult question and answer session. They asked me difficult (but relevant) questions such as, "Why do you want to leave your job?" and "Are you afraid of the impact of leaving your job before your first year expires?" I answered everything the best I could, but still felt that there was so much more that I could've said, but it would've gotten emotional.
At the end of the interview, they asked simpler questions and we laughed about my answers. We shook each others hands, and I quietly left the unit, just as I had come in.
When I got in the car, I was a nervous wreck; more nervous than I had been before the interview. I was scared that the interview hadn't gone well, that I'd be stuck at my miserable job until a few more years had expired and I would be a more solid ICU nurse. Somehow the thought of just having to stay in that place added to the terrifying experience of waiting for the results.
A few days had passed since, and yesterday I took the time out to e-mail my old nurse manager to thank her for the interview. I'd talked to one of my old co-workers on the phone about when she got her job offer as a nurse and she said that hers was only two days later. My interview had been last Wednesday... almost four days (discounting the weekend) later and I hadn't heard a thing. Discouraging news. I ended my e-mail to my nurse manager asking her when I should expect news on whether I got the job or not.
I got an e-mail back letting me know that, well, good news was yet to come. I smiled, jumped for joy, and ran naked through my apartment.
Say hello to your newest trauma I ICU nurse. :)
