Nurse Jobs London

Sunday night can best be summed up as “x out of 5″.as in: 3 out of 5 of my patients were DNR; 2 of 5 even knew who or where they were; 4 out of 5 were incontinent of poop, and that’s where my night went.

The patient admitted toward the end of the shift Saturday morning was still lingering, now on comfort measures only, with family sitting quietly in the room. I watched, fascinated, as her O2 saturation dipped to 71% and then 64%, though there wasn’t much change in her other vital signs. Surely she couldn’t last the night with that.but she was still there when I left. My lady from the nursing home Friday night was doing pretty well, responding to antibiotics, confused but pleasantly so, and thus no trouble at all. Then there was the other DNR, confused beyond belief, well-known to be a wanderer, and massively and odoriferously incontinent.multiple times. Compared to him, the dialysis patient next door, also incontinent, was nothing, because at least she didn’t holler and fight you when you were cleaning her up. And the guy who wanted his pain meds? Nothing to it, except that the docs were supposed to have changed him to oral meds so they could send him home Monday. (Guys? He can’t go home on IV Dilaudid for this problem!)

So that was my night.mass (mess?) confusion and cleanup. It could best be summed up by the occurrence at the end of it all when I was totally punchy. I was in with the aide cleaning up Mr. Stinky yet again. I was holding him rolled over towards me when he ripped a huge one. “That does it!” said the aide. “Next time I have to fart, I’m coming in HERE and doing it!”

I couldn’t help it. I lost it completely and we finished up both giggling like idiots.

In recent weeks there’s been a lot of it around. We’ve had an inordinate number of DNRs on the unit, a fact that displeases some who still seem to feel that Do Not Resuscitate = Do Not Treat. I feel that way about some of them, who are obviously in end stage something-or-other, but we get others who are not there quite yet and can be treated for an immediate problem that is affecting their current quality of life. Then there are the ones who *should* be DNR and aren’t, usually because their families either don’t understand or completely deny the reality of their situation. Those are the ones you just hope code on someone else’s time or unit (is sort of joke, ok?). I just wish the docs would be more forthcoming with the families and also with the patients, and would make some kind of decisions themselves about the appropriateness of treatment. How aggressive should you really be with a 98-year-old bedridden person from a nursing home who suffers from dementia, resists everything you are trying to do for him, hits and spits and is generally combative unless asleep, can’t swallow and pulls out feeding tubes, is incontinent of everything, etc.? I’m not saying play God, I’m just saying be realistic with the families!

The other night I had a patient transfer from another floor. He’d been admitted earlier in the day with probable sepsis, but his underlying diagnosis was an abdominal cancer with metastasis. When I saw him, I just got a sinking feeling. Sometimes you look at a patient and the first thing you think is “Boy, you gon’ die.” That was exactly what I thought. He just looked BAD. When I looked at his chart I saw that while he was not a full DNR, at least he was what we call a “Chem Code” which means you support his blood pressure if it bottoms out, but you don’t do compressions or intubation or anything of that sort. He floated along doing okay for the first part of the shift, blood pressure sort of on the low side but not anything unexpected. Around midnight I had to get an H&H (hemoglobin and hematocrit, a quick study for anemia) and when I got critical results I could see he was losing blood somewhere. Okay, nurse mode on. I woke up the on-call (not his regular oncologist who’d admitted him) and had to give him a complete history because he had no clue who this patient was and knew nothing about him. I got orders to type and cross and transfuse, which was about what I expected. Type and cross and getting the blood ready takes about 3-4 hours, so it was almost 4 a.m. by the time I was ready to get it going. That was also when the fun started. The patient complained of nausea and was given a basin; by the time my co-worker got back with the blood he’d barfed about 250 cc of coffee-grounds stuff, a sure indicator of GI bleeding. His blood pressure also dropped. I got the blood going at a pretty good clip, and his blood pressure continued tanking. After about 15 minutes we all looked at him and made the decision to call the house doc to check him out, a good move as it turned out. He took a look at the patient, called the on-call again (who basically washed his hands of the whole thing) and then had an extensive phone conversation with the patient’s wife. Meanwhile we were pouring fluids into him and running the blood as fast as we dared at the same time. He continued to spiral downward. I’ll spare the details for those faint of heart. At 7, one of my co-workers saw that I was overwhelmed and behind with my other patients, and he took over care of that patient since he was staying until 11. The wife had come in, and the last thing I saw of them, she was holding his hand and bending over him talking quietly. She had decided to make him a complete DNR. He died a short while later, very peacefully.just slowed down and flickered out on the monitor.

The next night I had my first experience of being floated.to PCU, not a favorite place, apparently, but one we have to go to frequently from our unit. For some reason they can’t keep staff. Things went along reasonably with my patients, three ladies with long drawn-out tales of home stress, and I finished my charting and was on my way to do something or other when I heard some commotion in the room directly across from where I was. “She’s in some weird junctional rhythm!” “Well, get a pressure!!” The next thing was “Call Rapid Response!!!” so I picked up the phone, dialed the number and got the Rapid Response team called and the house doc paged, and before I put the phone down it had turned into a Code Blue. People converged from everywhere and I got the crash cart. I didn’t really take part in the code except as a gofer and some handing of supplies, but apparently I was needed.

Twenty-five minutes later it was obvious that there was no bringing this one back, and the house doc called it. Everyone dispersed, leaving the usual hideous mess behind. About that time ER brought up a new admission and people got busy with that. The tech was getting ready to clean the code patient up so her family could see her, and I volunteered to help. That was when I realized who we’d coded. You can’t see the patient when they’re surrounded by nurses, RTs, and docs all working on them. But I looked at her armband in total shock. It was the woman I’d gotten to know while I was orienting to CCU.the one who had grown up in my home town, only a mile from my house, who knew where my house was as I knew where she’d lived, who’d gone to the same high school I did but years earlier, who’d married a flyboy from the local airbase and moved away. Somehow I was glad I was helping to get her ready for her final journey. I was able to tell her son, when I gave him a bag containing the few personal effects she’d brought to the hospital, that she and I had shared a connection and some memories when I took care of her, and he seemed grateful to hear about it. That circle had just come round.

The unit is okay, pretty much. It’s not a hard job; I think I said earlier that it was actually boring a lot of nights. The people I work with are nice, although a lot of them are refugees from units that are not happy places, and some are real burnout cases. The bitching from the regulars can be pretty wearing. Nights are long, much of the time spent just sitting around. And (shhhhhhhh!) sometimes we are painfully overstaffed, which is not the case in the rest of the hospital. I have read more books and spent more time online at work here than anywhere I’ve ever been.

Last night I got a look at the next schedule, and that REALLY pissed me off. My understanding when I signed on was that I’d be working weekends, and hopefully not ALL the holidays. I don’t work Thanksgiving (oh yippee) but I’m down for both Christmas Eve and New Year’s Day night. Not only that, but Christmas Eve is the fourth night in a row for me, and I don’t DO four in a row. Nor does one of the other travelers, who is down for four in a row the following weekend, and she’s pregnant. On top of that, everyone is working one or both of the holidays except for one traveler who for some reason is not scheduled for ANY! Fair? I don’t think so.

And then there’s the living situation. My apartment is actually quite nice, if small. It’s easy to keep clean and there’s plenty of room for me. I hate the driveway and the parking, but I can live with it. However.and it’s a BIG however.there is the matter of my upstairs neighbor. I have never seen her (I assume it’s a her, most of the residents here are travel nurses and female) but I have to HEAR her, and she walks *very* heavily. On top of that, she has a dog. Now, it can’t be that big a dog, because it barks in soprano, but when it runs through the house it sounds like a damn Clydesdale! And when she goes out and comes back, it does that for at least five minutes. Then it sits down and scratches and thumps on the floor for another five minutes. To make matters worse, it desperately needs its nails cut.just imagine a Clydesdale with jingle taps on its shoes. This morning I saw my neighbor come home just ahead of me (at least I assume it was her, looking at where the car parked). Oh goody, I thought, maybe she’ll go to bed! Ah, but it was not to be. Just as I started thinking about crawling between the sheets, she decided to VACUUM HER APARTMENT.the entire place.and the damn dog ran around in circles the whole time. If I ever have to live in another lower unit I will shoot myself.

On the other hand, for once we had interesting times last night. I came in to two patients and one on the way. My partner was one of the regulars, an LPN who’s almost finished with his BSN. We decided he’d take the one coming and I could have the two who were already there. My two didn’t look awfully complicated, as most of our patients don’t, but of course there had to be a curve ball somewhere, and danged if one of them didn’t come up with some lab work that indicated *maybe* she might have a blood clot in her lungs, so off she went for a CT scan. The other had come in with a potassium of 2.4, which is sort of incompatible with life, but she was getting IV and oral potassium and seemed to be doing better. The first one came back from her CT scan, and before too long I got the word that it was negative for blood clots. My partner’s patient came up from ER and he got her settled in. We were notified of another patient to come from an outlying hospital, but an hour later we heard that he’d decided he wasn’t going anywhere but home and had left there AMA (against medical advice). We kicked back for a peaceful night.

So I’m sitting there, minding my own business and doing a job search online, when the monitor starts alarming. I look and it’s my partner’s patient, and she’s alarming bradycardia (slow heart rate) in the 40s. Then her rate goes back up to the 50s.then down again.and keeps going down, 35, 32.I grab the crash cart and he goes tearing in the room and tries to wake her.heart rate is in the 20s but she responds, sort of. “How about some atropine?” He runs to get the drug. Patient is pale and clammy, but she’s responding after a fashion. Heart rate at the lowest I saw on the monitor was 18. Since I’m the RN I get to push the atropine, half a dose at first with no effect, then what the hell, give her the whole thing. And the heart rate starts going up.40s.50s.oh boy, finally a nice happy 74! We breathe a sigh of relief, wrap up the observation, and he goes to chart. Later he told me that the patient and her family had described episodes at home where she got pale and clammy and “felt real weak.” “Wanna bet she buys herself a pacemaker?” he said. Yeah, I bet she does. But I won’t find out, because they just called and put me “on call” for tonight; there’s one patient in the unit and two other nurses on the schedule. I could get called in for another floor, though I hope not. I’m nervous about staffing levels everywhere else.

I REALLY don’t like it here. I’m starting to think about a permanent job somewhere. Maybe not bedside, although I might think about that if the position were just right. Well, we’ll see. I have until the end of January to think about it.