Wednesday, May 28, 2008

Fun night

I wasn't with my usual night preceptor one night, though I don't think the events of the night would have gone differently if I was. Night.

One of my patients had gotten out of surgery earlier that evening and was to remain intubated and on the ventilator all night. Usually we try to wean patients off the ventilator and get the tube out as soon as the anesthesia has worn off sufficiently. Though I don't remember the one time I was on one, it's clear that people mostly do not care for ventilators. Instead of gently sucking in air as usual, patients now have a tube down their throat that blows air into their lungs. Unnatural, uncomfortable, and often anxiety-producing.

This young man was prescribed medication to decrease his anxiety and surgical pain. They weren't really keeping up despite a couple calls to doctors for increased dose and over the course of the night he was getting increasingly agitated. His hands were tied down with soft wrist restraints as we usually do with intubated patients who are not yet calm and rational enough to not grab for their tubes and IV lines. This guy was clearly not with it mentally, yet had the presence of mind to try wiggling down in bed so he could get hold of something to pull on. Several times an hour I had to readjust his position because he was close to grabbing his Foley catheter or airway suction line. Through rubbing it against the mattress, he managed to slightly dislodge the line going into his radial artery (the wrist) that measures blood pressure continuously. While I was trying to re-tape it, he yanked back and it came out. Great. I bandaged the site and got an order to follow cuff blood pressures instead.

With all this, and upon the advice of my temporary preceptor, I called a doctor to get the patient started on a sedation protocol where we could adjust a continuous drip of medication to the desired effect, calm and not fighting the restraints. Unfortunately, the middle of the night is not the best time to request the needed medication pumps as the supply staff is only a skeleton and take forever to deliver items.

At one point, I had to reach across this guy and hold his arm down because he was grasping at his chest tubes. These are tubes that are inserted between ribs or under the sternum to drain blood and other fluid from the chest after surgery. They also help reinflate lungs that have been deflated either for surgery or because of a pneumothorax (good picture of deflated lung and chest tube there). I couldn't go around the other side of the bed to readjust and retie his restraint because I was worried that during transit, he'd grab and pull his tubes out. I said, "Sir, I cannot let you pull your chest tubes out." He looked right at me and vigorously nodded as if to say, "Oh we'll see about that!" The other nurse in my pod had gone to the supply room and my preceptor had stepped away for a moment. So there I was leaned over the patient, holding his wrist, craning my head around toward the hallway waiting for someone to walk by. It was kinda funny. Kinda. After only a couple minutes, another nurse walked by and quickly came over to help.

Around 4:30 I started to give him his bath. My temp preceptor, who is a large, strong guy, held the restraints while I washed down the patient. Despite doses of medication before the bath, the patient was still agitated. The medication pump had arrived, but we hadn't titrated the medication up enough yet to have the desired effect. At one point while we were concentrating on his upper body, he managed to get his Foley catheter tubing between his toes and yanked on it. Um, dude. There is a balloon inflated in your bladder to anchor that catheter. You do NOT want to be yanking on that. Can you say traumatized urethra? Well, not with that tube down your throat.

Toward the end of the bath he settled down though. I was just finishing up redressing his surgical incision when the patient jerked suddenly and I looked up to see a look of shock on my preceptor's face. The patient, moving quickly, had grabbed a chest tube and yanked it out. My preceptor covered the hole with his glove and called for help, I ran to the supply room for some gauze impregnated with vaseline which is used to cover the hole so air doesn't leak in.

A couple other nurses came over to help and I paged the resident on-call to come reinsert the tube or suture the hole closed. Woken up in the sleep room, the resident was groggy when he called back and at first didn't really get what I was saying. "Just come down here now please," I said as nicely but firmly as I could. The patient wasn't putting out much fluid through the tube and had another one on the same side so when the resident showed up fully awake, he just sutured it closed. While he was working, early morning visiting time had come and I tried to head off the family before they came on the unit. I caught the mom in the hallway and explained the situation, worried she was going to panic. Nope. "I thought something like this might happen," she said looking apologetic, "He's a pretty anxious person usually. I sorry he's giving you so much trouble." Oookay, then.

From there, we switched to a different, more powerful sedation med which worked well. The pulmonary doctor showed up soon after, thinking she was going to be extubating him. "What's going on here?" she asked innocently. I told her the whole story and she sympathized. I paused the sedation med so she could see his behavior (it gets out of the system quickly) and within five minutes he was back to pulling and wiggling. By this time we were at shift change so I reported off to the next shift nurse and went home to well-deserved sleep.

A couple days later I walked by the same pod and saw the pulmonary doc. She beckoned me over saying, "Look here." I rounded the curtain and there was my guy, sitting in a chair eating dinner. Thanks to the amnesiac qualities of the sedation meds, he didn't remember a thing.

Tuesday, May 20, 2008

Night shift and getting the hang of it all

I've been working nights for a couple weeks now and it's going well. My night preceptor is great and I've learned a lot from her. It was up in the air how long I'd be with her before I'm off orientation and working solo. At the end of last week, we both agreed that I needed more practice caring for unstable patients needing interventions such as vasoactive drip titration (regulating the dose of constantly delivered IV meds to keep heart rate and blood pressure within certain parameters) along with a second stable, but still critical patient. Managing both while still making and receiving calls, delivering scheduled medications, completing paperwork, and drawing labs, all within the alloted time, is a skill I've yet to completely master. Then of course I also have to be using critical thinking to work out what's needed when.

Monday, May 19, 2008

A beautiful thing

I laid down for a little cat nap tonight and unintentionally fell into a deep sleep where I had an incredible dream. It was late at night and a big group of my friends ringed a microphone set up in Mybloody's front lawn. We were playing a gorgeous song. Some had acoustic instruments: guitar, orchestra bells, viola, banjo, shakers, wood blocks; everyone was singing. It was a gentle, sweet song cut with a fair bit of longing and even though the words were sad, we kept looking at each other and smiling as we played on and on and on.

When I woke up to the roar of the A/C fan, I laid in bed stunned by how wonderful it all was. Then I scrabbled for a tape recorder, trying to hold on to the melody. Like many dreams though, it faded away and didn't make much sense when I tried to get it down on tape. I admit I teared up a little, both for the idea that my friends and I had made something so beautiful and out of frustration that I'd lost it.

I'm not convinced that dreams are a window into the subconscious, but this dream integrated two things I love very much, music and my friends, in a way I wouldn't have in my waking life. So friends, pick up an instrument today or just sing and try to catch a moment of joy or fear or sadness. I'll do the same.

Tuesday, May 13, 2008

The Art Guys - Nothing To It

After a work shift on Saturday 5/3, my preceptor dropped me off at the University of Houston so that I could see The Art Guys' show Nothing To It: An Evening of Itty Bitty Witty Ditties. Despite the trying-too-hard-to-be-humorously-obnoxious name, it was a lot of fun. The Art Guys are a Houston institution. I won't recount their biography, you can read that here. In brief, they are performance artists with an emphasis on the fun and funny rather than the dull and ponderous.

This show was a retrospective of their work performed in front of an audience that was clearly heavy on their friends, family, and ardent supporters. The first work sounded like a good idea, but in practice only partially worked. Called Future Music [In Three Movements], a projector displayed instructions that each audience member should, at a random time during the rest of the show, shout out one word. As soon as the description was up, people started calling out. The words were almost exclusively nouns like asparagus or chicken, you know "funny" words. And once the children got started, oh man was that annoying. Again, good idea for a piece, but when the audience is full of wannabe comedians and hyperactive, bored children, it don't work no good.

I won't go through every piece, just hit the highlights. A great work that worked was Kiss Piece where the two Art Guys applied lipstick and kissed every member of the audience. It was funny and sweet. Good friends and (I think) family got kissed on the lips, bald guys got kissed on the head, shy little girls on the hand. I can imagine that for a different audience it could be uncomfortable or even hostile (which would also be interesting), but for this hometown crowd it went smoothly. Kiss Piece was immediately followed by Guzzle A Beer - At Any Time - (For Tom Marioni). It's exactly what it sounds like. For the rest of the night, the director would intermittently flash up the title on the projection screen and the guys would crack open beers and guzzle them. Near the end they handed them out to some of the other back-up performers and even one guy in the audience. Seeing as the guys aren't really party animals, it was more to be endured than enjoyed, at least after the first round.

Inverted Karaoke was great. Jack, who cannot play, sat at a piano and attempted to perform "Bridge Over Troubled Waters" while listening to it on headphones that blocked out all other sound. Michael, equally horrible, "sang" along while also listening to headphones. It was cacaphonous and hilarious. Another mostly auditory work was Wrap Piece where the guys pulled out giant rolls of industrial-strength plastic wrap and proceeded to stretch it around rows of seats and handrails, working to express all the squeals and thrums they could. Plywood was a visual spectacle with dancers and chorus singing the praises of plywood. While fun to look at, this elevation of a mundane object to glory went on too long.

The last piece was also the most serious. Entitled For Martin, Jimmy and Bill, it consisted of Michael breathing audibly into a microphone while Jack slowly turned a rain stick. Sounds kind of lame, but in the near-dark, as a meditation on breath and the end of life, for someone like me that cares for people on ventilators every work day, it was beautiful and moving.

The whole show was filmed and will air on the Houston PBS station at some point. There are photos from the show on their website as well as clips from other performances.

Monday, May 12, 2008

Amorous RN, or how not to be accused of same

During a brief moment of live TV, where as I'm usually watching something recorded by my Tivo, the weekend weather guy for the Houston CW affiliate was doing his thing. I was a bit dumbfounded by his name, Casanova Nurse. Really and truly, that's his name. Unfortunately his bio does not reveal the provenance of such a unique moniker. I like that he (most likely) does NOT live the life that his name could have dictated, skillfully wooing then abandoning patients in an endless string of medically-based conquests.

On that note, last week I was advised that I should make sure a female nurse or patient care tech was present whenever I examine female patients and to leave bed baths to the female staff as precautions against allegations of impropriety, which have ticked up recently. With the pain, lack of natural light (and therefore cues to the time of day), dearth of quality sleep, medications for pain and anxiety, or just idiosyncrasies, patients who've been in an ICU for days can become confused and somewhat paranoid. For instance, even in my short time working I've seen several patients who think that all staff discussions are about them, including gynecological surgeries for men and imminent childbirth for elderly women. Good thing I have a psych background, it's useful.

It's rather annoying that I have to be so cautious as I have no interest in molesting my clients and I can't really imagine a nurse getting in to this line of work with that intention. Still, better safe than sorry or as we often say, CYA.

Tuesday, May 06, 2008

Up all night

I started working nights this week. My schedule in general is:

- Wake up at 5 PM
- On the bus to work at 6:05 PM
- Work 6:45 PM to 7:15 AM
- Home by 8:00 AM
- In bed by 9:30 AM

Soooo much better than waking up at 5 AM. On my days off I'll wake up and hit the gym, do laundry, and grocery shop before those places close at midnight, then enjoy the peace and quiet of the night. At first I'm sure I'll do a lot of reading and movie-watching, but I do plan to go on some photo excursions around my neighborhood and finally get out to the music clubs to see some bands. A social life would be nice as well.

I was going to advise my friends to avoid calling me during the day, but I accidentally left my phone on yesterday and didn't wake up despite three separate calls. Yay for the air conditioner/white noise generator in my bedroom.