Friday, February 29, 2008

Brutal day

Thursday night I came home dejected. It was a brutal day at work and I thought, "Do I really what to do this? Can I do this?"

My preceptor has been fairly aggressive in pushing me to take on greater challenges during my orientation. Rather than follow a gentle curve of increasing difficulty—stable post-operation day 2, AV fistula, fem-pop bypass, and so on—we've been leapfrogging ahead as she feels I'm ready. Her assessment of my ability is inevitably higher than my own. She's not cruel or anything, just confident that I can handle it. She's always there when I drop the ball on details, which I do more than I like. I've been doing great with transfers out to less acute floors and stable patients so she wanted me to get more practice admitting patients fresh from surgery. On Thursday we took two empty beds and bided our time with a staff meeting and a discussion of medications.

Our first admitted patient had just undergone a carotid endarterectomy where the surgeon opens the carotid artery on one side of the neck and removes the plaque that is either narrowing the artery or is unstable and may rupture. I haven't seen it done myself, but I've been told it looks like they're scraping out chicken fat. So eat healthy and exercise! On the scale of things, it's not a big surgery. The patient had already been extubated (breathing tube removed) and was awake. I needed to assess her status, keep her blood pressure under control so she wouldn't blow the carotid sutures, and monitor her neurological status on the small chance she could have a stroke. There's other stuff too like talking to family and giving meds, but the first three are the big ones.

She's was doing well and then her urine output dropped. Almost all the patients out of surgery have a Foley catheter in that drains their bladder. It's important that we accurately record their output and after anesthesia it takes awhile for conscious control to return. We like to see at least 30 mL an hour out showing that the kidneys are being adequately supplied with blood to filter and that they are doing so. Less than that for two hours triggers a call to the doctor. In this case, doctor wanted a rapid infusion of fluid running in, what's called a bolus. Problem was that this patient's IVs were running into veins in her arms rather than a larger, central vein. Run the fluid too fast through her peripheral IV and the vein could blow. Which it did. Not really a big deal, saline running into the tissues is going to cause some localized swelling and maybe some soreness, but no serious effects. Luckily the patient had another working IV in her other arm so I switched it over and took out the blown one. These problems, low urine output then blown IV from the fluid bolus, are minor. You have to do something about them, but fairly easy to handle.

So she's mostly squared away when the next patient rolls out. This patient had multiple coronary artery bypasses and was coming out mechanically ventilates and unstable on multiple IV medications to maintain his blood pressure, heart rate, etc. I'll talk more about what a patient who's had open-heart surgery goes through in a future entry, but basically they've had their sternum cut open, heart stopped, bypasses sewn in, heart restarted, sternum closed with wire, and tubes inserted to drain fluid (or possibly air if a lung was collapsed for the surgery). Heavy duty stuff. This guy was quite unstable and had me running for hours trying to get everything done.

I don't have much experience titrating IV medications (increasing or decreasing rate of infusion to keep say, systolic blood pressure below a number set by the physician), in fact we weren't allowed to regulate them while I was in nursing school. I worry about that because while I understand what they do, all I know about dosing is "start low and go slow". The nurses at work tell me that I'll pick up what to start them at and by how much to bump them up or down. Can't come soon enough for me. Whenever this patient was starting to get out of range and my preceptor wasn't immediately available, I would be saying, "Uh, [fellow nurse] which one should I turn up and by how much or maybe I should just wait and see? Ack." Hard to detail what all happened but we had doctors seeing him about five more times for additional orders, procedures, and intense staring at monitors. Keep in mind that I still had that other patient who needed to be monitored, medications given, etc. At the end of the day, I stayed 30 minutes after just to finish all my charting—documenting my narrative of what happened and what I did about it.

Exhausted, I trudged home from the bus stop thinking, "Am I in over my head here? Maybe I should have just gone to a regular ICU."

Wednesday, February 27, 2008

Nurse humor

The other day I was listening to some nurses talk about patients having to go back to surgery because of excessive bleeding. "Yeah, sometimes they have a prolene deficiency, hypoprolenemia," said one to gales of laughter. I didn't so much get it. Later I discreetly asked my preceptor what I was missing. Prolene is a kind of suture material the cardiovascular surgeons use. Now that is funny.

Heh. Uh, so -emia means "concerning the blood" and hypo means "below normal" so the comical neologism hypoprolenemia means "the surgeon didn't put in enough stitches." See? Hilarious. Less so cause I had to explain the whole thing, but still funny. Well, maybe not to the surgeons.

Tuesday, February 26, 2008

Spoiled rotten

I forgot to mention this earlier, and this is hopelessly dorky, but the unit where I work has a stat lab to rapidly process our lab samples. Just a couple mLs of blood and I can get a CBC, BMP, and blood gases? With results in five minutes? Glory be.

Monday, February 25, 2008

What I do, Part I

I’ve held off describing my job because I wanted to get my head around it first. It’s going to take a good year before I’m comfortable in my role, but I think I’ve got the basics down enough to at least sketch in an outline. I work in the CVRR, cardiovascular recovery room. The purpose of the unit is to receive patients directly from the operating room where they’ve undergone surgery on their heart or vasculature, recover them from anesthesia, and stabilize them to the point where they can be transferred to an acute care floor or ICU.

Some of the common surgical procedures are carotid endarterectomy (removal of plaque to prevent further blockage), coronary artery bypass graft (CABG, or “cabbage”), heart valve repair or replacement, femoropopliteal bypass (fem-pop, should be a music genre), and arteriovenous graft creation for dialysis. We also get transplant patients - heart, lung, kidney, and I think liver – but that’s much higher level nursing than I’m capable of at this point. The workflow right out of surgery differs according the procedure done, but generally the receiving nurse sets up the bedside with monitoring (which displays EKG, blood pressure, heart rate, oxygen saturation, temperature), suction for oro-nasal and/or chest tubes, oxygen, and supplies like tubes for lab blood draws. When the patient wheels in the nurse hooks up the lines, takes report from the anesthesiologist, and does a rapid assessment of the patient.

Assessment is a huge part of a nurse's job, whatever area of care they're in. It means collecting data such as vital signs, the look and feel of a patient, the statements they make and documenting it to establish trends. It's also the first step of the nursing process known by the acronym ADPIE, assess, diagnose, plan, intervene, evaluate. The nursing process is how nurses organize their care. I'll go into more detail about patient assessment in a future entry.

Getting back to the fresh surgical patient, the goal is for the patient to remain stable in terms of blood pressure, heart rate, oxygenation, etc. This is often accomplished with medications given intravenously. Doctors will write an order like, "Titrate to keep SBP <150." This means the nurse will adjust the rate of infusion of the specified medication so that the systolic blood pressure, the top number representing peak pressure, is maintained below 150. Learning the medications used and why, the interactions between them, and the starting dose to the max dose are pieces I'm slowly acquiring.

Man. I just read over this and realized that I've left a lot out. By way of explanation I'll say this, there's a thing that happens to nursing school students about halfway through their first semester of upper-division classes. They're not civilians anymore. They have a hard time talking or even thinking like non-medical professionals. When they try to explain something, their speech is full of acronyms and jargon before they backtrack and start again, trying to translate effectively. The ability to summarize complex info and relate it on a developmentally appropriate level takes a while to catch up, if it ever does. All this is to say that I forget sometimes how much medical stuff is crammed in my head that I take for granted. So, if I vacillate between being overly simplistic and talking far above your heads, just let me know.

Whew. This post really just flew off the cohesion rails. Oh well. I'll get the train back on track tomorrow.

Friday, February 22, 2008

I think the word I'm looking for is awkward

Today one of my patients was doing well after her surgery and so her doctor wrote orders for her to be moved out of ICU to a telemetry floor where she would be monitored constantly for cardiac problems via wireless EKG. I went through the normal process of a transfer, faxing a written description of her status to her new floor, calling a verbal report to the receiving nurse, disconnecting the IV lines she didn't need anymore, getting her into a rolling chair for the trip, all that. I called the waiting room and asked that her family meet us in the hallway for the trip.

We chatted pleasantly as we rolled to the elevator. I got in first pulling the chair in after me backwards. This is so if there's an emergency, the patient is facing forward. The family filed in after us and we're off. Only we started going down, not up. Oh well, no big deal right? We'll just go down a floor or two and then right back up. At the second basement level, I heard and felt the back door opening. "Dang, please don't be what I think this is going to be."

A quick look back confirmed that yes, the back door was opening because a few undertakers were bringing a body out from the morgue. Oh joy. It was covered of course and dead people don't really bother me, but I was acutely aware that the family of a rather recently critically ill heart patient were staring right at the guys in dark suits and a body bag on a gurney. Thankfully the patient was facing the other way. We all avoided looking at each other and the undertakers stepped back to let the door close. But it wouldn't.

Sure it would start, but then it just popped back open as if to say, "Are you sure you don't want to get off? Really? I mean the morgue is right here." The nervous chuckles stopped after the third time. Finally, dinging and shaking, the door ker-rawled closed on the fifth attempt amid the clearing of throats and intense floor-staring. All I could think was, "I've got to say something. What's the right way to transition from a very real, non-metaphorical confrontation with death?" I went with a far-too-effusive description of her new, private hospital room.

Saturday, February 16, 2008

Missing Austin mightily

I've got the profound homesickies.

I miss my friends and the bats and the tower lit orange and a friendly, laid-back populace and the (only slightly smug) awareness that I'm in the oasis that is the political desert of Texas and thinking of how great the park system is every time I drive along Lamar between 15th and 29th and wandering around Emo's waiting for the music to start and fairly-good-to-very-bad art on the walls of every damn coffee shop and cafe and seeing the stalwarts at the SXSW volunteer call and flipping through the new used records at End of an Ear and breakfast tacos on the morning of tests and sitting in the balcony at the Paramount and waiting forever for my burger at Casino El Camino and and and.

Being away from them, I appreciate how wonderful it truly is to have so many long-time friends. Back in Austin I regularly hung out with people I've known for 8, 12, 15 years. That depth of shared time and experience is...I don't know what I'd be without them. It's a downer to have to start over some place else. Frankly sucks is what it does. I'm determined not to wallow though.

Now, can someone tell me where the cool people with knowledge and reason who like making and appreciating all manner of art congregate in Houston?

Tuesday, February 12, 2008

My favorite moment from SXSW 2007

Standing next to my friend when he was so overcome with joy at Bob Mould's solo acoustic set that he ended up in tears. It was very touching to see a friend's love of music just spill over like that. Yay music! Yay friends!

Monday, February 11, 2008

And you thought getting body checked was rough

Hockey player Richard Zednik is in stable condition at an ICU after having his carotid artery sliced by a skate blade while playing last weekend. I'm not big on hockey, but I am a huge fan of carotid arteries. Especially keeping them intact and patent. The video is not explicit, they wisely avoid showing a lot of blood. Watch the end to see the freak accident that caused it. I hope he recovers without permanent neurological damage.

Friday, February 08, 2008

The squirrel who looks like a tail-less cat

While going through stuff I've had stored away, I came across what I can only guess is the first story I ever wrote back in 1st grade.

The bike ride: An illustrated story

The text reads,

"Wans I took a bike ride. I saw a tree and a hill and a filld of flowrs. Well at that minit a squirrel jumped out of a tree. And landid on my bike I rod my bike home and cap the squirrel for a pet and I howp I have anothr avichr."

My spelling has vastly improved (what's with all the missing "e"s?), but sadly my illustration skills have not.

Wednesday, February 06, 2008

A bit of advice I picked up recently

If you ever find yourself reading a book that, judging from its cover against common wisdom, is full of sardonic observations meant to produce mirth but regards a subject with which you are currently struggling so that instead of laughing out loud or even wryly smirking you are forlornly gazing out a window at an overcast sky or even quietly sobbing, then put that book aside until some distance is achieved. It'll be funny in a year.

Monday, February 04, 2008

Lentil soup

While listening to a bunch of songs last night, I prepped the ingredients for lentil soup. Here's all the ingredients ready to go into the crock pot.

Lentil soup ingredients
Not pictured is the bouquet garni, the little bag of seasonings that makes the difference between a bland bowl of sustenance and delicious tummy-so-happy time. I don't pretend to understand spices. Aside from dill and rosemary, I have no idea what most of them do to influence the taste of a dish. I just trust recipes and throw in the bay leaves, tarragon, whatever.

I got up in the morning, threw everything in the pot and went off to work. After a about 9 hours of cooking, here's the messy blending part.

Lentil soup blending
Here's the soup. Sure it looks like undifferentiated brown slop, but damn it's tasty with parmesan cheese and a hunk of crusty bread.

Lentil soup final

Sunday, February 03, 2008

Weekend back in Austin

Went back to Austin this weekend to visit friends, pick up some leftover items from my old house, and do some shopping. Friday night was an art opening at End of an Ear where I bought a bunch of music. Then it was off to El Azteca for dinner. Their tamales are far below my gold standard (Curra's), but previously I've loved their mole and the salsa is always incredible. Next door was a hideously excessive Valentine's Day display in a flower shop. This shrimp appears to be allergic to itself, check out those lips. And what the hell do shrimp have to do with VD anyway? Not a shmoopy animal like bears and kittens. The night ended back at Mybloody's where we just sat around and goofed off.

Saturday was all about the acquisition of material objects. A good, steady paycheck will do that I've ascertained. At least I was buying books, music, movies, and furniture. Except for that last thing, I was very happy to be spending money at Austin businesses. Yay for shopping locally. The furniture was from IKEA. Yeah I know. I just needed to something cheap and decent looking. I only need it to last a few years.

Mybloody was all faux-exasperated that I hadn't ever been before, so he showed me how it worked. Thanks buddy! And of course at IKEA we gays run into other gays Mybloody knows. How embarrassingly cliche. Saturday night was a sedate one at Joolie & (name withheld cause I don't remember if he's amenable to being publicly identified)'s. I had to leave early to go to sleep as A) I'm on that sort of schedule what with the getting up at 5 AM for work and B) I had to get the rental car back to Houston.

After a nice, sedate ride back to my new apartment on Sunday, I did laundry and assembled furniture. All-in-all it was a fun, productive weekend though far too brief.

Friday, February 01, 2008

Where I do the nursing thing

Thursday was my first day taking on the total care of a patient on my unit. I wasn't that nervous as my preceptor was three feet away and this patient wasn't as high acuity as others I taken care of in the past. What was different was that I didn't have to ask the primary nurse to get medications for me or print the paperwork for blood draws for the lab. I was the primary nurse. I talked to the family on the phone, discussed the patient's status with the doctors, and endeared myself to at least one nurse on the night shift by bathing the patient before shift change. A good day.

I haven't really talked about the unit where I work. It's called CVRR, cardiovascular recovery room. We get patients right out of surgery for coronary artery bypass grafts, heart valve repairs or replacements, dialysis fistulas, heart transplants, anything to do with the heart or vasculature. The idea is for the patients to be on our unit for a limited amount of time, around a day, before they move on to a regular intensive care unit (ICU) or a monitored floor (called telemetry or just tele). Right out of surgery, the primary concern is keep them hemodynamically stable (heart rate, cardiac output, blood pressure, etc. interacting well to maintain the patient) while they recover from the anesthesia. As soon as possible, we want them off the mechanical ventilator and moving about. There's a lot more to it than that but I'll save some for future posts and for a time when I actually understand it better!