Humbled

Since I have become a radiology nurse I have witnessed something that has humbled me; cancer patients and the infallible strength that they have.

My role in radiology is different from my role as a bedside nurse. I am still responsible for patient safety and care but in a more indirect way. I monitor the patients during their MRI’s and I am the one that starts the IV’s before the study begins. I encounter a lot of oncology patients. In fact, I would say almost 90% of my patients some days are getting scanned to assess for metastasis, diagnose new cancer, or stage some form of cancer. These are people from all walks of life. All races, all statuses, all religions, all education levels, all ages, cancer does not discriminate.

What has humbled me is their attitudes. Almost every cancer patient I have come in contact with in my department has had a bright smile and a sunny personality. Most of them come in with the mindset that they have another battle to fight and they are going to win it. I love that! Their smile makes me smile. We end up joking and laughing during our time with each other. These are people that are getting a procedure that could potentially present more bad news and yet they walk around with a smile. I wake up bitching and moaning in the morning about having to get up so early. I complain about my knees being stiff or my back causing me pain. I rarely wake up and just thank God for being alive and being *relatively* healthy. I am going to make a real effort to try and change that. If these oncology patients can still tackle life with such vibrancy then why can’t I? Every day that I am alive is a blessing. Every day that I am blessed to not have to experience the things that these wonderful patients are having to go through on a daily basis is a gift. I am humbled yet inspired by the strength and positivity these patients demonstrate. I’m going to live for them.

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Full circle

I started working in a hospital on my birthday in 2007. In this particular hospital, there were two separate transportation teams. One did regular transports and discharges and the other only did transports to and from radiology departments. I started as a transporter in the radiology department. The hospital offered a free EMT-B course, all you had to do was pass. Of course I took up that offer! I transported for over a year and in the process started nursing school. That’s when I decided to become a tech. After graduation, I worked on that unit (med-surg) for two years. I hated it. I am not a med-surg nurse. I got frustrated very quickly with all the frequent flyers. I felt like I wasn’t making a difference. No matter how much teaching I did I knew I would see those patients in a month, maybe two. So I left the hospital to take an ICU position in a smaller hospital. It was hell for me to go from a teaching hospital where I was autonomous and a part of the care team to a community hospital where I was supposed to just do what I was told. Yeah, no. They got two years out of me as well before I took an ICU position in another teaching hospital. I loved it. I learned so much and got to be a part of things I had never experienced before. The only drawback was the commute. An hour and a half one way, and I was working night shift.  I managed to pull this off for three years. I kept telling myself I would move closer to the hospital but I never did. I love the city I live in right now. I love the diversity, something that was lacking in the area that particular hospital was in. So, I started the job search again. Guess what hospital and what department were in need of a nurse? Yep, my first hospital and the opening was in radiology! I jumped at the chance and luckily got the position.

Its been a bit surreal. Being back in the radiology department feels familiar and new at the same time. Most of the radiology techs and nurses were there when I first started. They remember me as a transporter from 11 years ago. Now here I am in their department as a clin 2 nurse! I’ve come full circle.  I am getting used to being the new kid without actually being a new kid. Maybe, just maybe this is where I was supposed to be all along…

 

Job hopping

How long do you typically stay in a position in your nursing career? For me, I have had every nursing job (just started my fourth one) for at least two years. Two years gives me a broad view of my position and allows me to decide if this is what I want to do and is there where I want to do it.

I’m sure there are some of you reading this and thinking “two years is a long time to figure out if you want to be where you are!” For me, not really (keywords: for me). I feel like the first year I am trying to become proficient in my job. I’m the new kid, I am learning how things are done here and establishing my own routine. Essentially, I am getting into my groove.  I learned that when I am the “new kid” I get frustrated and irritated easily and often times blame the job. I go through the “I don’t like this job” phase, not because the environment is bad but because I am not great in the environment and I can be a bit of a perfectionist. That second year is when I am really evaluating my job. By the second year, I am good at what I do. I know my skills, I have my routine, I know this place. I know my coworkers. I know my doctors. I know what type of patients I will see on a consistent basis. I know how the hospital works. I am typically in some sort of leadership role by the second year. This is the point where I can take an objective look at where I am and whether I want to continue. Do I really hate this job? Is it the people? The environment? Do I not enjoy this patient population? Am I burnt out? I feel like I can really make a less biased observation at this point. My “two-year” thing is not something I expect other people to embrace. I do feel like one year on the job is enough for some people to figure out if they like what they are doing. And let’s be honest, those of us that have had more than one job can think of one place that we have worked where we knew we were in the wrong place before we hit that first year!

What I wonder is how soon is too soon to bounce to the next job? I have some nursing friends that have had several jobs in the same amount of time that I have been in one place of employment. Experience-wise, I would assume that it looks great to a potential employer. I mean, this person looks like they know a little about everything. However, I also wonder if having several jobs for a short amount of time makes a person look like a job hopper? Do some hiring managers see this as a “red flag”? Would a manager want to invest in an employee that may leave quickly? I have asked a few people that were or are responsible for new employees and they each said that they look for a year at least.

So if I have any hiring managers reading this: what are you looking for? How soon is too soon to go from one job to the next? Do you even pay attention to how long we are in a position?

“It’s ok, we’ve got it”

I don’t trust this phrase whenever it comes to my patient any other medical professional or anyone for that matter.

Why?

Because I’ve seen it come back to bite people.

The patient needs to go to the bathroom, you go in to help. The family says “it’s ok, we’ve got it”… Annnnnnnnd your patient is on the floor.

They want to place a central line at the bedside so you go in to assist. The fellow tells you “I’ve got my med students so it’s ok we’ve got it” annnnnnnnd then they proceed to place a femoral central line in the right subclavian because the student didn’t know the difference between the kits (this is a true story).

X-ray comes in for the morning film and needs to reposition the patient, you offer to help. They tell you “it’s ok I’ve got it” annnnnnnnd now your IV is ripped out and on the floor.

As far as I’m concerned, you don’t “got it”. Don’t you touch my patient without me being there. I’m going to help whether you like it or not. I do NOT have time to fill out safety events. I’m probably not even done with my regular charting.

It’s ok, I’ve got it.

Log off

Log off of your computer, nurse!

I know you’re just going to go into the room of your patient for a few minutes. I understand that you just need to go to the pyxis and grab one more med. Log off.

You have very personal information about your patient visible for anyone to see. EVS, the random med student, the family member/friend in the room (for those of you with bedside computers), they can all see this very personal information.

How would you feel if one of your friends found out that you tested positive for opioids on admission because your nurse left your labs open on the computer in your room? You’re sedated and intubated so you can’t remind the nurse to protect your personal information.

Doesn’t sound fun does it?

Your patient and their information deserve that same respect.

Even more importantly, it’s law. You have been given the responsibility to maintain patient privacy and you should take it very seriously. You’ve heard of HIPAA. You know just how important it is. Understand just how serious it is to your medical facility. Nurses have been written up, suspended, even fired over HIPAA violations.

Don’t be that nurse.

Get into the habit of logging of when you walk away from your workstation. It may seem tedious but it is your duty to protect that information.

97 victims

Most of us entered nursing to heal, to help, to try and save lives whenever we can. There are some people in our field that have joined for all the wrong reasons. One such person is Niel Högel.

I came across an NPR article (click to link to the story) about a German nurse that was serving a life sentence for two murders… They believe he may be responsible 97 more. NINETY SEVEN.

He said he did it for the thrill. He enjoyed the feeling of being the hero after resuscitating the patient. Unfortunately he wasn’t always successful. Patients lost their lives for a thrill.

As a nurse and former EMT, I will say providing care in the most critical time does give you an adrenaline rush. You get to a point of functioning on sheer instinct. That sense of accomplishment can really make your day. However, I have never craved that feeling so much that I thought of harming a patient to achieve it. I don’t know what brings someone to that point. When reading his story I wondered, did he become a nurse to pseudo-save lives or did this need develop as his career progressed? Were there warning signs in his outside life? Were there warning signs at the bedside? How many lives could have been saved? I just can’t wrap my head around it.

That’s so gross

You would think the grossest thing that I have seen as a nurse would involve the patient.

Oddly enough, no.

I can say for sure the grossest thing I have seen is the patient’s family member(s) sleeping on the floor of the room.

DO YOU KNOW WHAT HAS BEEN ON THAT FLOOR?!?!?

I have walked into the room and nearly tripped over a family member sleeping peacefully on the floor. I was immediately freaked out. Like, what makes someone think sleeping on a hospital floor is safe or sanitary?

Oh, you have to get up off that floor honey.

There have been soiled linens, blood, body fluids that I can’t describe, EVERYTHING on that floor. Glare all you want but I’m not leaving you down there.

People think hospitals are far cleaner than they actually are…

Consent and ethics

Nursing is fully aware of consent. We know that we need to have documentation that the patient accepts this treatment. It’s a no brainer. But, what if the patient doesn’t want treatment and the power of attorney does?

Prime example, you have an elderly patient that is obviously letting the family talk them into surgery. To no one’s surprise, it doesn’t go well. They end up sick. They have to remain intubated. They need an art line, central line, pressors, the works. Even on the ventilator they are adamantly shaking their head no to all the things you’re trying to do. They are fighting. They keep trying to pull away. They don’t want this.

Their family does.

The POA is who the doctors decide to ask for consent to treat. They completely bypass the patient. They’re intubated, they can’t answer for themselves right? If course the family wants everything done… So, everything is done. Is that fair to the patient?

Shouldn’t the patient be allowed to say no without having someone else choose otherwise? What is the fine line that decides when a patient no longer has the capacity to make their own decisions? Does intubation automatically take away that right? Does having a POA take away that right? If a patient is clearly communicating, even in the vent, shouldn’t we respect their wishes?

The nurse in me says yes. The nurse in me says to respect my patient’s dignity.

The nurse that’s been at the bedside for almost 8 years knows that that is normally not the case.

I have seen advanced directives ignored because the patient is unconscious and the family isn’t ready to let go. I’ve seen cases like the one mentioned above. I’ve seen doctors watch as the family is almost forcing a patient to go along with treatment and the doc just goes along with it as well. I’ve had to be a part of “moral distress” meetings because nurses were stressed over the ethical dilemmas involved in certain cases. When do we stop?

PJP and HIV

Most of us are aware of HIV and how it affects the body. We have been taught how the virus attacks and destroys the immune system. It is not the attack on the immune system that directly kills a person.  It’s all those opportunistic infections that eventually weaken and often times finally kill HIV/AIDS patients.

PJP, “pneumocystis jirovecii pneumonia”, is one of the most common opportunistic infections to befall an HIV positive patient. This particular type of pneumonia (or as one of my patients pronounced it “ammonia”) is caused by a fungus commonly found in the environment. For those of us with a normal immune system, it does us no harm. For the immunosuppressed patient, however, it can be dangerous and possibly deadly. For a patient with severe PJP, it can lead to ARDS which has a high mortality rate. Having HIV does not mean a patient will automatically become infected with PJP. The infection typically manifests when the CD4 count is low. This is a really good article describing PJP and its relationship to HIV/AIDS. Here is another good article by Medscape that talks about the fungal pneumonia and how it functions.

You are probably wondering what made me write a blog on a type of pneumonia that you may not have heard of before. Well, I am a nurse and also a state certified HIV tester. HIV is becoming a passion for me. However, that’s not the only reason. See, back when I was a med-surg nurse, we had a patient that I can’t forget. He was a 22-year-old young man that was in and out of the hospital with chest pain, complaints of difficulty breathing, fever, and other rather generic symptoms. His chest CT showed the opacities in the lung. The doctors were sure he had pneumonia but he didn’t respond to most therapies. Furthermore, he’s a young guy, he shouldn’t have a recurrent pneumonia presentation like this. Enter our infectious disease doctor. He decides this guy needs a bronch. We are done guessing, he wants to get a bronchial sample so we can figure out what is going on. They began testing the sample for what type of pneumonia it was and it came back as PJP. He immediately asked for the patient to be tested for HIV. The resident nor I really understood why. Of course, I had to ask. His response? “When I see PJP I think HIV.” I asked him what he meant by that. That’s when he began to tell me about the fungal infection and its relation to immunosuppressed patients. In his words, “you just don’t really see it in people with a healthy immune system. Our guy wasn’t a transplant patient. He wasn’t on chemotherapy. So, what other reason would a man his age possibly be immunosuppressed?”  Turns out, he was HIV positive and did not know. His CD4 count was terribly low. I witnessed this man’s life change in the blink of an eye. He didn’t take the news well, but I couldn’t blame him. That was not the last time I saw him. He was in and out of our unit with pneumonia or thrush. He wasn’t really compliant with his meds. No one in his family knew what was going on with him. He wouldn’t allow visitors while he was in the hospital and would sit in his room all alone. It was heartbreaking. Then he stopped coming into the hospital. I held out hope that he had finally started taking his meds and got better. Deep down, I knew that wasn’t the case. Turns out he did come back into the hospital, just not to our unit. This time he was intubated in the ICU. He didn’t make it. He was just too sick and had been sick for far too long. Because of him, because of his case, I will forever remember an obscure pneumonia that I haven’t treated since.

So, I thought I would share a little bit of obscure information because… well… why not?

Are there any cases that stand out to you? Leave a comment and let me know.

“Do you have any allergies?”

How often do you ask your patients about their allergies? Better yet, do you clarify and ask about medication and any other allergies?

We get in the habit of trusting our doctors who order the meds and the pharmacy that verifies the meds. However, we may need to get into the habit of asking about food, medication, and “any other” allergies on admission.

When doing the admission database I used to always ask whether the patient was allergic to any medications. That’s all I figured I needed to know… until a patient was negatively affected.

Way back when I was a Med-Surg nurse there was a patient that needed a CT scan. No big deal, he tolerated the scan fine but his kidneys, however, did not. We started noticing his BUN and creatinine creeping up, his urine output decreasing, all for no apparent reason. He just didn’t look as good as he should. He said he has had a CT scan before and never had any trouble. He had no known allergies. He was not a renal patient. It didn’t make sense! One of our nurses happened to be in the room giving him a saline bolus to see if we could get his urine output to pick back up. He was questioned about his previous CT scans again and this time he mentions that one time they “put something in his IV “and it “made him sick and put him in the hospital” but “that was years ago.”

Oh really?

Well, guess who had a CT scan with IV contrast… Mind you, he said he had no allergies. Turns out because of his education level he only considered medications to be the pills he took at home so the IV contrast allergy didn’t register with him. I don’t think he even understood that his reaction was an actual allergy.  He didn’t really know what IV contrast was and since we only asked about meds, he didn’t see a reason to mention it.

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Looks like we found our problem guys.

Needless to say, that changed how I asked about allergies. I try to keep my patient’s education level in mind when asking questions. I want to make sure they understand what I am asking them. It is my job to keep them safe. As the nurse, we are often the last safety check before something reaches the patient. We block all the foolishness from getting to our patients because we are awesome.

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