Published Apr 17, 2000
Nursing in Nevada
I was there when Dee was overwhelmed. Again, the madness overcame us all during the usual "change of shift, discharge the old ones, give them new ones, damn the acuity's" philosophy here at Desert Storm Hospital. I was at the nursing station, desperately trying to "check my own charts," and had overheard her exasperated plea to the available MD while she pitched her rationale for sedation for one of her patients. I kind of had a feeling who she was talking about, but wasn't really sure. That was until I turned the corner to go check on my own "mad woman" and saw 224 A lying on the ground in the hallway. There was another "nurse-type" employee from an enemy unit standing over her, looking at me with great disgust and shouting, "why don't you get some help..." or something like that. She was kind of indignant, really. Gave me a feeling of "This isn't my job" type stuff. I took it personally, but blew it off.
I made my way to the nursing station, taking a quick, en-route visual check on 220 A (I had purposely turned his face to the doorway so that I could see his 02 cannula while "walking" by in times like these. Ok, this time I was fast-walking. Never run in a hospital, etc...) I yelled out "patient down" and started "running" back to the end of the hall. All the way to the end of the hall. You know, where they put the patients that need closer observation. I did a quick visual of the screaming customer and figured that she had a heartbeat and satisfactory blood pressure. She had to have a strong heart to pull this one off while maintaining the ability to rant and rave about the quality of care in one the "Top 100 Hospitals in America." The "nurse-type" was there with her and telemetry hadn't paged anyone for 5 minutes so I triaged myself into the room. Or what was left of it. I saw a chest tube suction container lying on its side. That made me go back out and take another look at her. No, she had quite sufficient lung volume. And vocal volume. That was very apparent. And there were no hanging tubes, no dripping blood. (I kind of like dripping blood. Brings out the wolf in me.) And, I've got to tell you, a lot of what she was ranting about was making a lot of sense to me. Yep. This was change of shift at DSH and I was on her side. While looking for blood, I noticed another patient across the hall who was up out of bed stripping his clothes off and on the verge of joining her in the hallway for who knows what. It was kind of surreal, the way the light from the window shadowed his determination into a faceless figure of confusion. Was he confused? Or was I? With so much drama at hand, the ticket prices would be handsome, indeed. Checking back into reality, I triaged him out of this present urgency, while keeping him in the back of my mind for further entertainment value to come.
Again, I went back into the bunker. Apparently the unhappy camper had "sawed" out of her restraints using a fork and had successfully made it to the hallway before falling down and screwing up the day of the "nurse-type" that had the misfortune of happening upon "our little secret" here on IMC. I had a quick mental flashback to my own "should have been one-on-one" patient that I had hoped would remain tied more securely so that she could not pull out her remaining, and quite marginal IV. I had trusted her (such madness within me) to leave her foley alone during the past three days I had taken care of her. She did leave it alone. Honest.
On my next trip into this den-of-despair, I found a heplock cap on the floor. So, I went back outside and saw that the IV seemed intact and the slide clamp on the line was locked. Best nursing anywhere. And by this time the only charge nurse for the whole damn unit had arrived (the supervisor had left early--after all, "we had a lot of discharges...") and was doing her best on-her-knees psych-nursing on short notice, but making slow progress. Still no telemetry monotone "check the lead" pages, so back into the "room." There was just something about this "room." Room 224. If I never have another patient in this room that would be okey-dokey with me. Then I remembered her roommate.
Her roommate had been kicked out of ICU 2 days ago and I put her in "B" bed about 0945. (She wasn't my patient today, though, or yesterday either, for that matter.) They had successfully fixed her lower extremity occlusions, and, of necessity, were keeping her blood thin. I remember this because she had started bleeding at full moon/change of shift. It was around 1700, she was on a heparin drip and trental and had pushed her call light "with no response after a minute" after she discovered she was bleeding. Lucky she was awake at the time. She screamed out loud and the charge nurse of the day had happened along. I spent the next hour in her room, which, of course, took me off the floor for my other patients until a joint decision was made to do a fem-stop clamp "maybe for another forty-five minutes or so." Yeah. That oughta' do it. This was after the phone call to the MD at 1710, which only amounted to "hold pressure for 20 minutes" and do the post-op vital sign thing. I told him she was hardening around the site. "I'll see her tomorrow." Being the "proper" nurse, I didn't say, "Wait a minute, you didn't hear me, she's still on heparin and trental and getting a healthy hematoma, you might want some labs or something like that." But it was, after all near change of shit. Shift. What was I thinking, anyway?
So, this obscenity- spewing (since I'm in the mood...) Transylvanian Devil just couldn't have had a nicer roommate to be found anywhere. What a lucky customer she was. As fate would have it, I didn't have the "bleeder" as a patient on the next day, but I hear that she wore the dreaded fem-stop all night long and then some. Finally, the heparin and trental were discontinued, and yesterday I was called in by a lab person to draw some blood out of her heplock. The nurse that had her was probably at lunch, so whoever was covering now had responsibility for 8 patients, and I was in the vicinity. I wasn't her nurse at the time, but like I've mentioned, I like blood and seek out the opportunities to find it. The sign above her bed read "no needle sticks" just as it did two days ago, and there was a cotton ball on her right antecubital, which wasn't there two days ago. I didn't say anything. And I can keep a poker-face better than anybody. So the lab girl handed me the tubes and I filled them as the patient said, "They didn't do that earlier..." which made me look at the sign again. "...they just took it out of my arm." The lab girl said, "It wasn't me," which I had already known, and I told her, "I know you didn't do it." And I started to cover, saying that she was "off blood thinners now," la-de-dah, just trying to keep the peace. I know the lab girl felt embarrassed for her co-workers--I could see it on her face--but the poor patient had already been through hell and flat on her back for almost 48 hours. And now she had this roommate right out of a jack-in-the box in a Felini film. Glad she wasn't my mom.
Anyway, I asked the "bleeder" if she was ok. She now had that "Desert Springs" look on her face, usually reserved for 13-hour shift nurses after a three-in-a-row. Or one good hellish one-in-a-row. Like Dee's day, today. It was kind of like the look I had on my face right then and there. She was sadly serious and quietly fed-up with her ordeal, but she had remained the proper citizen through and through. "I turned the light on...she needed some help I guess..." perfectly understated considering the hurricane that had just left her room for a breather of hallway air and a chance at freedom.
By this time there were at least two other nurses in the hall, another nurse putting clothes back on the patient in 223B, and the blood pressure machine was clanging for the patient in 223A. He was running 205 over something. And my new change-of-shift transfer from CCU was at 199 over something. My guy in 220A's tube feeding wouldn't run, he needed another good suctioning to save his remaining brain cells, And 219B wanted to be discharged NOW and to catch a cab back to the brand new Paris hotel that gave him Las Vegas Chest Pain Syndrome. Topping it off, 221B was now, just now, getting louder and louder, laughing and yelling in Chinese. No English at all. Never was. Just Chinese. And of course, a "pleasant" type of dementia which allowed everyone to check a "4" box on the acuity sheet when a "16" would have been more appropriate. But a "16" isn't available. Not that it would matter, but it kind of makes you feel like it will matter when you check that box. Like that will get the next shift more help. Not your shift, mind you, but the next shift. Empowers you some how. That little box says, "This patient needs more time and effort for their safety and your sanity." And they always want the acuities filled out. Sometimes they get them, and sometimes they don't. I know this because the sheet up front isn't filled up with checks and numbers after I'm ready to go home, and I've been just as guilty at not having the time to fill it out either. And it's missing a box for "new admit or discharge" which should also equal a 4 or so. And filling out the acuity sheet is fairly acute and time absorbing in itself. Tell me again, how do they staff using acuities? But, that's what this is all about.
So she's tied to the bed, playing with the phone, telling me I'm an idiot in Chinese, and basically having a swell time. Being an opportunist, I'm starting to learn some Chinese now, I think. And she can say, "thank you, thank you very much." You would think that she would learn a little more English. Words like "I'm going to take some blood now" and "this won't hurt very much" through Pavlovian techniques associated with needle sticks. And they tell her every time, whether she understands it or not. Even her Chinese cardiologist (unnamed here) said that he doesn't speak Chinese. (So why does he have an accent?) But, after repeated English trials and needles, the only thing I've heard was "thank-you-thank-you-very-much" launched with a big goofy grin on her face. Oh, to be pleasantly demented in a few years from now...or tomorrow.
I secretly had hoped for a quick escape into the night without any further travels to China, and, lucky for everyone, she was "safe" in her vest jacket with a new, coherent, hypertensive, fresh-off-the-vent-today "baby sitter" in the next bed to watch over her.
My new change-of-shift patient had arrived with the usual family gathering of witnesses, (no babies in bassinet's in this group, however,) including a very nice, quiet spoken daughter. "I haven't seen my mother in two years. Can I sleep in a chair next to her tonight?" I said "Sure. Do you speak Chinese?" Well, we all had a good laugh over that one, including the Chinese woman, who really was a sweetheart anyway, despite her confusion. And she had left her IV alone all day, which is why I had loosened her restraints. She simply yelled out less and seemed calmer because I had made that executive decision. And, yes, I had considered the risks associated with independent nursing judgment
Now, I mentioned the "babies in bassinet's" because of the curious visitor rules here at DSH. It's "Come one, come all," despite suctioning, infections, dangerous equipment, and minimal working space. I remember walking into one room to answer a call light and was surprised to see an 8-year-old girl laying fully clothed on a freshly-cleaned, rails-down, way up off the floor bed. Management doesn't' care. Mom didn't either. Count me in. But it was strange seeing a comatose great-grandmother with her tracheostomy oblivious to the crying newborn laying beside her head for a quick family picture. Future pediatric patients, future income I guess.
Again, room 224 had a beckoning mental reputation with me now, and I did my best to remember who had suffered there. Surely something out of a Stephen King novel had taken place there, years ago when organized crime was visually in control. There was an Hispanic woman, wiggling, writhing all over Bed "A" just last week I think. She was relatively quiet when I got her, and then the chameleon changed its colors towards the infamous change of shift. I refused to take her back the next day. She was handed off to a number of nurses each day, each refusing to endure the abuse from both patient and the family, and "the room." She was another "no-code" status here on IMC which gives false assurance to family members that I just can't explain away, other than for financial-legal issues. The medical floor, as I understand it, gets a five-patient load maximum with no telemetry (and no telemetry breaks to cover...) and the additional help of nursing aides. The patients are less acute, aren't they? I think if I had to, I'd rather lie down there, than up here. In "the room."
After her free psych consult, the squeaky wheel had now earned herself a private room, again at the end of the hall. This was merely luck, because the private room had only been empty about an hour. She now had probably 5 of haldol on board which was patiently begged through a telephone call using the Nurse/MD relationship (one out of five patients respond to haldol), she was wearing fresh restraints and still hissing her displeasure at the hands of her keepers. (I just know this will all come back to haunt me some day...an overstressed nurse will be slamming haldol into me and clinching down my collar...maybe tomorrow, perhaps?) I know this because I have just had to go back down the hall into the room dragging the crash cart because telemetry (remember telemetry?) came running out, wagging a strip of paper with a 12 second run of v-tach in her hand on you-know-who. It was fun pushing the crash cart. Always is. You get lots of attention and draw wide-eyed stares of wonderment from anyone in your path. No matter how slow they are walking in front of you with their own laundry-trash-food carts along the way. After all, it's change of shift.
I help get the blood pressure cuff on the customer while slapping her face (not that I enjoy having to do that), noticing that her skin was too pink to have symptomatic v-tach, (before I slapped her,) and I got a slow moan with 132/80 and a rate of 160. Strong heart. But not as strong as the over-stressed nurse who is responsible for her care (with a five patient load here on IMCU/M.A.S.H/Telemetry). While her nurse takes her pulse, I take her nurse's pulse and notice that, while not really fast, it is thin and she is cold and clammy. I didn't ask her about her medical history. Or whether she had eaten lunch. (I heard that no one on night shift got any lunch breaks, so there was "probable cause" to ask, but I didn't...) The patient was now happily metabolizing off her sedation in preparation for the night shift, her nurse was still standing up, talking, and making appropriate decisions, and this time there were a lot of nurses there, nurses from everywhere, nurses from outer space. (The crash cart draws em' like flies.) So I figured I was now free to go suction my guys airway and control my gals blood pressure, in that order. There was still charting and I&O's to consider too, but that's never been too much of an issue here at Desert Storm Hospital. Time constraints take care of all that. I've learned this too. And QA means, "quit asking."
Again, don't get me started. California was big on QA. Which usually meant that there was a little more money to go around and hire a 220-person education department at my last hospital. I have never gotten over that and never will. So I had to mention it here.
Anyway, during suctioning, I'm very thankful for my patient's nasal trumpet, and earlier, I had the foresight to drag a bunch of suction kits out when there was a break in the action, somewhere before my 1410 lunch break. But it beat my 1710 lunch break. Which will always beat the day when the LPN working telemetry didn't get one at all.
It also helped that this patient was right across the street from the supply room. Also, my ambulatory patient in 219A would wander out and check on him in curiosity, pondering his own fate and future here on IMC.
Being ambulatory, he had walked in with a heart rate of 25, but now, a newspaper article and an electronic pacemaker had "saved" him. He sat, and walked, reading bible verses quietly, perhaps appreciating his second chance. "That poor old guy over there looks like he's having trouble..." he would tell me, and his vigilance had come in very handy today. But he was discharged at 1530. Although my personal "patient load" fell, I had lost another visitors set of watchful, caring eyes. He came back about 45 minutes later and dropped off a couple of thank-you cards for some favored nurses, again thanking everyone, and quite thankful himself. He took another look at 220A, we shook hands and he left.
Now it was time to get a handle on the blood pressure. The only prn's available had been given at 1500 and couldn't be had until 1900. It was now 1835, she had emptied her bowels and bladder (pressure still didn't go down) so I just prepared the prn vasotec IV and was ready to give it. Nice and slow so that by the time it was in, it would be 1900 and would keep everything nursing-administration/damn-your-independent-judgment legal. But right then and there, with needle in hand, I got an overhead page for another phone call. Well, what the hell, they transferred her down here from CCU with a BP 190/? so another legal precedent has been set and I'm not responsible. Maybe. Anyway, it's kind of too early for the drug, and she looks ok, so I'll go take the phone call and go placate the wife of the "poor old guy."
She had called 6 times that day. She was on oxygen herself and quite ill too. In addition, her daughter lost her husband two months ago. It was the whole, sad story. But I wasn't finished charting and losing five minutes times six phone calls takes 30 minutes that DSH wouldn't let me have. (Just glad that I didn't have to do telemetry relief. And I got MY lunch.) And there were other patient-check calls too so figure an hour out of my day.
"Is he doing any better?" she asks for the sixth time. And I deliver the half-truths that she's asking for, using my own psych-nursing skills, all-the-while hoping my new admit doesn't stroke out from the high anxiety excitement and entertainment that she has been assigned. And all at no extra charge, courtesy of her confused, somewhat increasingly agitated at change of shift roommate.
I needed to get back to my blood pressure, but another nurse had asked me if I had talked to the president just now. She said that she had just seen him, and most people knew that he was supposed to come up and see me some time this week. I assured her that it was 1900 or something and figured that either she or I were delusional. Or did she say that last night? He wouldn't be here now, anyway, would he? Not at this hour. But that would have been great. I'm still willing to talk, but now I insist that he don a pair of tennis shoes and walk a 12-hour shift with me. Maybe on nights, too. After all, I was ignored.
Now the vasotec was in, the blood pressure was down and it was time to give report. Truthfully, well past time to give report. I hunt down the next shift nurse (who, incidentally, tells me she was cancelled last night, and I remember that night shift didn't get lunch breaks. But the hospital saved her salary expense and the money will go to good use in the spanking new, cost-effective addition next door.) She was visibly perturbed and wanted to get started with her day and I was holding her up. But we've all been in the same situation and I can tell that she's got a ton of experience because when she saw me, she knew I was no longer to blame. I start report but then the daughter of the hypertensive comes to get me because my Chinese patient is trying to get out of bed. At change of shift.
I get her out of bed and on the commode, because it just so happens that the daughter of "A" bed is "a private duty caregiver" in real life and just "knows" that she needs the commode. What the hell, I put her on the commode, the Chinese keeps flowing and she's laughing some more, and I tie her down and hand her some toilet paper. She loves this, and happily starts wrapping it around her hands in preparation for the event. I hang the foley closer to the commode after making damned sure she sees the urine in the bag. Ya' never know. Maybe she'll add it up.
I went out and finished report to the next shift, who can tell things have gone to hell when the dinner tray cart is still in plain site. It was there for the crash cart event too. It's 1930, and by all rights I've given report, won't have to go to church this Sunday because I've done my duty, and I can leave. But my China Doll is tied to a commode chair and that's not kosher. The night shift nurse still has to get more reports so I know she won't be in there for a half-hour, at least. And "private duty" is standing in the hallway.
I went back into the trenches and saw that the friendly, low maintenance, keep-em-dry Foley was now out and lying on the ground. Maybe I will go to church. On the way home. If I can ever leave.
I went back to get the next shift nurse, who gave me the well-expected requisite lecture about "tying her hands," etc. We both went back to put the patient into bed, and tied her securely. I knew Miss Hong Kong wouldn't be laughing anymore that night. And the blood pressures next to her would continue to climb. And the "private duty" daughter would keep the night nurse busy with all kinds of helpful hints and suggestions. And, of course, the commode was empty.
It was now 1945 after my three-day-ride through Desert Storm Hospital, here at one of the "Top 100 Hospitals in the whole damned US of A." And I didn't need any medication, and I didn't cry and complain.
And so I headed for home, first stopping at the downstairs phone to warn my wife and ask her if she wanted me to pick up any food and drinks on the way. She knows that if the phone call comes late, it's simply been more of the same. We come to a mutual decision, I make the 12-mile trip in 20 minutes, while stopping to pick up some chicken and a couple of vanilla malts. I've made it home. The automatic seat belt grabs my arm and one of the malts hits the ground, exploding like 900 cc's of urine out of a freshly emptied foley bag at change of shift. (Yesterday.) I know that she has a heart of gold and will insist that the remaining malt is mine, no matter how much I protest. So that was the last straw of another hellish day and I break down on the trunk of my car and have a good cry in the parking lot.
My despair was not long lasting, however, because I remembered that today, Dee didn't cry. She had another assignment from hell and assumed the responsibility for it, with verbal protest and no response. Here at Desert Storm, reports and patients are traded like playing cards. The jokers don't pay off in the long run, both for customers or staff. I've seen Dee cry before, but not today. Maybe she's given her all, or has just given up.
As for me, I woke up the next day and wrote another letter. Ok, perhaps more of a novelette. And it was primarily a therapeutic exercise to eliminate some stress and perhaps share the overall "feel" of nursing in Nevada. Along the way I did contemplate starting the necessary re-write so that it can be understood by a broader audience--maybe the local newspapers, or even The Hollywood Reporter. And I love computers as much as I love blood, so there's always the Internet. So please forgive the run-on sentences and "lack of discipline" as my English instructor would have put. I'm tired.
Again, I have made another promise to myself to check the want-ads, make the phone calls, and knock on some more doors, and find a job that offers the piece of mind and higher compensation earned by a short-haul truck driver. They may never get to push a crash-cart, but the money and benefits are surely better for them than for me, here in Nevada. I did it last week despite the fatigue. I'll do it tomorrow.
And I also lost the protest at home. Hiding my tears on her shoulder, I hugged my wife and drank the malt. It was very, very good.
Jerry Murphy, RN
I enjoyed reading the posting. It brought back memories. I worked midnights at my current job. The staffings minimal on midnights. And still is. I wrote a letter much like the one above. It was directed to nursing administration. And spoke about a night on my unit. And my concern about staffing. Nursing administators never answered my letter. The unit supervisor was supportive, but couldn't give us additional staff.
I just want to say. The posting brought back memories. In fact, I went back and read the letter. And still to this day I don't know how I made it through, that night. Let alone 8 months...on midnights with little staffing. Currently I work afternoons. Staffings A LOT better on that shift. And I'm happy.
I wish I knew how to paste the letter here. But I don't. Good luck!
Jerry That was wonderful and so funny My night like that included being nine months into a difficult pregancy big as a house and miserable physically. We do somuch with so little and no one who hasn't been there can understand both the satisfacton and the frustration such a shift can generate.
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