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…

 

“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.

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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Charge

I’m a charge nurse on my unit. I actually wasn’t comfortable taking on that role but my coworkers thought I would do well so I said ok.

Some days I regret that decision.

Don’t get me wrong, I do enjoy having new responsibilities. I like seeing nursing from a different perspective. I rather enjoy the decision making that is left in my hands.

I do not enjoy the stupidity that I encounter. For instance, our OR and ER are fully aware that because of the way EPIC is set up, we need an admission order placed by the physician so that bed center can place the patient on our bed board. If the patient is not on our bed board then we cannot pull them onto our unit list and thus we cannot get into their chart once they arrive to our unit. If we can’t get into their chart then we can’t see their orders. If we can’t see their orders then we can’t carry them out. They know this. It never fails, however, the doc will call us to tell us they need a bed but not put in the order. Once they arrive to the unit, they want to look at us crazy because we can’t start carrying out their orders and draw admission labs. It is now to the point that if the admission order isn’t in then we just don’t take report. Why? Why do we have to go through this!

I also do not enjoy the micromanaging. There is a list that charge nurses have to carry out each night. I have to check and see if everyone’s admission database is done, whether each patient has an up to date blood band, whether each patient has ICU and blood consent, whether each patient with restraints has an up to date restraint order, and whether or not each patient has a daily weight. Because heaven forbid we hold nurses accountable for their patients! I understand some of the list. I know when I have patients I rarely check the admission database. There are typically too many other things taking place for me to worry about that at 0034 in the morning. Consents though? As the nurse, I should be checking those. I feel like it’s micromanaging. More importantly, how are nurses going to form the habit of checking for consents and active blood bands if I am always doing it for them? It is my least favorite thing to do and everyone knows it.

Overall, I am still glad that I decided to become a charge nurse. I have a greater understanding of why assignments are the way they are sometimes. I understand how difficult it is to decide who is getting the next admission. I understand the frustration involved with moving patients out just to make room to get patients in. I realize now that the reason I am just learning of the admit I am getting, because ER is on the phone to give me report, is because the charge nurse is just learning of the admission as well. Things that I used to take as a personal strike against me no longer bother me. I realize the charge nurse doesn’t have the time to spiteful. It’s too damn busy for all of that. Being in charge has given me a whole new perspective.

Nursing and mental health

Nursing and mental health go hand and hand. Nursing is hard. Nursing is hard not just physically but emotionally. We hold everything in because we are the ones that are supposed to help. We heal. We often forget that we can sometimes be the ones that need healing.

I was diagnosed with depression years ago, years before I became a nurse. I was placed on meds that I no longer take, I’ll explain why later on. Nursing school didn’t help, it just kept me so busy that I couldn’t take a moment to acknowledge the depression. Nursing, especially in a hospital that I hated, added anxiety attacks to the picture. I would wake up at night in a panic without being able to pinpoint why. That made me feel worse. I felt like an idiot for panicking over nothing, which made me hate myself even more. It was a downward spiral.

Before nursing school, when I first voiced suicidal ideation, my parents sent me to therapy. That is when I first received the diagnosis of depression (my mother died when I was 16, I watched her take her last breaths, I shut down big time). I was placed on trazodone and Zoloft. I hated it. I went from feeling depressed to feeling nothing at all. So I stopped taking both of them (don’t be like me) and instead stuck to therapy. It worked for me. She helped me come up with other ways to manage my mental illness. It worked for quite a while. Then enter nursing school and full-time nursing. I ended up back in therapy but due to my schedule I just couldn’t keep up with it. Hey, I’m a nurse, I can figure this out on my own. I’m tough. I’m a fixer. I’m a healer. I help everyone else so why can’t I help myself?

I am my own worst enemy.

I wear a smile for my patients and my coworkers. I am happy Fred the nurse. I’ve got a smile and a joke. My patients love me. My coworkers love me. Everyone believes I am ok. I look like I’m ok. I also spend most of my off days sleeping, I’m talking 12-13 hours. I don’t want to leave the house unless it’s to get food. I isolate myself from my friends, my brother is my roommate and he may not see me the whole day. I have dark thoughts that I know I should not be having. I wake up with my heart pounding feeling like some unknown thing is wrong and if I don’t fix it the world will implode. I am Fred the nurse and I have depression. I am Fred the nurse and I am not strong enough to battle this alone. I am Fred the nurse and I am strong enough to know that I need therapy again. I am Fred the nurse and I will get out of my own way. I am Fred the nurse and I will be ok.

 

So many diseases!

I had no idea there were so many diseases until I became a STICU/transplant nurse. Our unit takes care of surgical and trauma patients of all different types (except cardiac, we have dedicated units for that). While trauma is not easy, it can sometimes be a little more straightforward. Most of the time, if it’s bleeding make it stop. If it’s broken, fix it. Every trauma case is different of course but the path you take is typically easier to identify.

Surgical cases are a whole different story. I have come across so many different diagnoses that I have never even heard of. My first time hearing about Budd-Chiari syndrome was with a liver transplant patient we just treated. I have had to spend so much time looking up things on the internet trying to figure out why my patient has 70cm of small bowel left. I have learned about spinal disorders, blood disorders, neurologic disorders. I spend a lot of time asking our specialties to explain this diagnosis or that surgical procedure.

I love it!

Granted, I can’t tell you half of what the hell was explained to me. I can’t remember a majority of the diseases I have looked up. I have “nurse brain”. I know it for as long as I need to know it and then I purge it with alcohol to make way for the next round of sh*t I need to know. No shame. I plan on doing what I see some of our med students and residents do. I am going to get me a small notebook that I can leave in my locker at work and document the diseases that I come across. I haven’t decided if I am going to just list the name of the diseases or try and include a description with each so I can look back through the notebook and learn. It’ll probably be the latter.

Hopefully, I can start sharing some of these diagnoses and diseases with you all.