Monday, August 27, 2012

Its been pretty busy at work lately and I have been having some pretty sick patients, too, lately.  To be honest, I can't even remember everything these last several shifts and I haven't, obviously, been blogging regularly, to keep things fresh in my memory.  But I can say one night during shifts 97, 98, or 99, I literally had one patient dying in one room (he turned out to be a "Do no Resuscitate" patient, more on that in a second) and a patient continuously having seizures in the next room.  Trying to juggle two critical patients at once is no easy feat, let me tell you, especially after needing to go with the patient who was seizing to CT Scan right after you just coded your other patient.

So more about my "Do not resuscitate" patient:  He came in feeling weak, not eating over the past several days, and pain in his right leg.  He had multiple myeloma, a form of cancer, and was in his 80's.  His blood pressure upon arrival in triage was low- 80 something over 60 something.  Textbook normal is 120/80.  He actually came into the ER prior to me coming on shift and when I got there, I took him over as a patient.  His blood pressure at that time was like 113/70 something.  Better.  I kept him on continuous BP monitoring, but he was taken off of it when he went for some tests.  When he got back, fluids were ordered and a blood transfusion were ordered.  I went to get the blood and the fluids, started running the fluids and checked his BP which was now 80 something over 50 something.  Not good, going back down. I opened up the fluids to run as fast as they could and put the bed in a position called Trendelenburg, which is where we raise the bed up and then lower the head of the bed.  This ensures that while the BP is low, the brain will still get the blood flow it needs.  I checked the BP again, still not improving.  I waited a couple more minutes, checked again- now 64/46.  I went to get the ER doctor and told her his BP is still going down after fluids and Trendelenburg.  She went into the room and the patient was increasingly less responsive.  She decided to call a code so that we could intubate the patient as his oxygen saturation was tanking too.  He had a pulse but was essentially not responding to us.  The family was there and before the doctor intubated, she talked with the family, who then advised that they would not like to have the patient intubated and their wishes of no CPR were also expressed.  So basically that all meant that we would wait for him to die on his own without intervening. The patient received 2 units of blood and 1 liter of fluids and his BP was still not improving much.  He was admitted to the medical floor and I called the nurse up there to give report, but after I gave report, the patient became more unstable and my charge nurse said he would probably die on the way up, so we should just let him stay in the ER.  Sure enough, his heart rate started to slow, went down into the 40's.  Patient still had a faint pulse.  Then the patient's heart rate went to 0, and his pulse was slightly there, my charge nurse told the family they should say their goodbyes and they did.  That, for me, was the hardest part.....hearing the granddaughter say, "Goodbye, Grandpa, I love you," was all I could do from bursting out into tears.  I just held the hand of the wife until it was her turn to say goodbye.  So strange how you can be home not feeling well, decide to go to the ER, walk in, and then die later that night.  You just never know.

I've had severe cellulitus (infection) of the leg, acute respiratory failure, abdominal pain, ear infections, sore throats, broken ribs, broken knee sustained from a car name it, I've probably had it.  I like my job, I love learning.  I've been giving some medications lately that I've never given, so thats been pretty neat.  The only thing I can say I don't like is that we have a lack of tech help at work.  I wish that could change because it would certainly make my job easier and help me take better care of my patients.

I'm back at it again tomorrow.  I work Tuesday, Wednesday and Saturday this work week.  Until then...

Thursday, August 9, 2012

I worked a lot this past week, having 4 days in a row, and one day off in between the other 2 shifts, so I haven't had much time or energy to post.  But the good news is I did a few really cool/new things.  

Shift 92:
Patient came in complaining of having car battery acid getting into his eye.  The doctor ordered some anesthetic eye drops and something called a Morgan lens to irrigate the eyes.  I had to insert the lens into both eyes and the lens was connected to a liter of normal saline IV fluid, one liter for each eye.  The liter of fluid irrigated the eye through the lens.  Quite interesting.

Shift 95:
Patient came in from fire rescue who was napping and when the family went to wake him up, he just had a blank stare and was having aphasia- trouble communicating.  Doctor came to the bedside to evaluate him and decided to call a stroke alert.  A stroke alert is called overhead throughout the hospital and basically tells the lab to send someone over right away to draw blood, tells the CT department to make sure a machine is clear for the patient to have an immediate CT scan, tells any other staff in the department to come help.  A neurologist is immediately called and usually comes to see the patient within 30 minutes.  The CT scan is used to determine if the stroke was caused by hemorrhage (blood) or ischemia (a clot).  This patient's stroke was ischemia, so the decision was made by the neurologist and family to administer a medication called t-PA (tissue plasminogen activator) which is a highly potent medication used to bust up the clot.  There is a chance of the patient hemorrhaging, so its important to get a good history from the patient's family to see if they are a candidate.  It can also only be given within a 3 hour window of onset of stroke symptoms, and I read somewhere that only 3-5% of patients make it to the hospital in time to received the medication.  However, I don't know how accurate that statistic is since I've seen 3 patients get t-PA in the last couple of weeks.  To give the medication, you give 10% of the total amount, based on the patient's weight in kilograms, during the first minute.  Then you give the other 90% over one hour.  Then the patient has to stay in the ER for 30 minutes to 1 hour after the infusion for evaluation.  Then the patient goes to the ICU.  I'd like to see how his is doing now because he was still very aphasic when he left the ER.  The medicine takes a little time to work, so I am hoping there was some improvement for him.

Shift 96:
Patient comes into ER, around 8pm-ish, complaining of not being able to urinate since 11am.  We inserted a foley catheter into his bladder, but there was no urine.  We tried irrigating it, which means we take a syringe of saline and push it into a part of the catheter and its supposed to break up any clots if there are any.  Still no urine.  Doctor then ordered a bladder irrigation, which is connected to bags of fluid which continuously run into the bladder to help irrigate it.  Still no urine.  The ER doctor then called the patient's urologist who said to stop the irrigation and that he would come in.  He tried a couple of things, which didn't work, but then decided to insert a suprapubic catheter, which means above the pubic area, a hole is basically cut through the skin and a catheter is inserted into the bladder there.  It is stitched into place.  This finally worked for the patient and urine was draining into the foley bag.  I assisted the urologist the whole time, so that was cool.  I even had to run around the hospital at one point to find a bladder scanner, which is like a small ultrasound machine used to see how much fluid is in the bladder. The urologist wanted that prior to inserting the suprapubic catheter.

So thats all my interesting info for now.  I am off for 6 days, so no posting for a while.

Until then......
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