Nurse Jobs London

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.