5/01 WILTW: Margaritas and Oral Thrush

Nurses General Nursing

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I've been asked to start the WILTW thread, and I'm more than happy to!

This has been an exciting week for me, as it was the last week of my Med/Surg I rotation. I'm trying not to feel too relieved though, because finals are next week. That being said, I will still absolutely squeeze in time to catch up on GOT.

This week I learned:

That my clinical instructor is a big ole softy. I can't believe that I thought she was super scary when the rotation first started.

That having just one year left of nursing school doesn't feel like enough time. Don't get me wrong, I feel like I've learned a ton in the one year of school I've had (and I'm more than ready to graduate so that I can get my social life back), but when I think of just how much I still don't know, I get a little worried.

That I wish I could take some patients home with me. Throughout clinical, I had nice patients, but none that really lingered in my thoughts when I went home for the day. But last week I had a patient who had already been through so much. His whole family had already been through so much. Sometimes it's hard to know just what to say, and I hope I was more helpful than I felt I was.

That I'm probably going to have a lifetime of telling family members, I'm not a doctor. You really need to talk to your doctor about that. I will probably NEVER be able to diagnose you.”

I've also learned that said family members, when you actually do give them advice (such as dietary advice), will say Oh, you're just regurgitating what you've learned in school,” and will continue to eat everything under the sun while wondering why their blood pressure isn't controlled. Why yes, I am telling you what I've learned in school, but apparently you'd rather hear that steak for every meal paired with a margarita is the best possible chance for survival.

That being said, I do follow the steak and margarita diet. But hey, I'm working on it.

That the best way to get a resident to like you is to empathize. Let them vent. Losing my independence is something I can hardly fathom, and I'm sure I wouldn't handle it with grace. (Like, really I'm very certain that I'll be the LOL trying to escape everyday and falling out of my wheel chair in an attempt to lunge out the door). It's ok to let residents feel angry about it. It's ok let them know that, yes, it does suck, and that you'll be right around the corner when they're ready for help.

But it's not ok if they scratch you. Or bite you. Oh swear at you. We still need some limits.

That I will never ever forget to do an oral assessment on my patients. This is the second time I've shined a penlight in there and found a massive case of oral thrush.

On that note, I'm also very glad I'm not a dentist or dental hygienist. I'll wipe all the butts in the world, but don't bring that mouth any closer to me.

But what's grosser than the grossest mouth? Maggots. I was not pleased to learn that maggots are still being used for wound debridement. That...is my limit.

So what did you learn?

Specializes in Emergency Department, ICU.
I feel like that's every hospitalist ever. My ICU isn't closed, so the hospitalists can admit to us, and I just want to throttle every single one of them. They always just want to sit on the patients before they make any decisions. I had one go unresponsive with an O2 sat in the 70s on 100% BiPAP before one of them agreed to tube my patient. I thought the guy was going to have to arrest to get a tube. If a patient gets admitted to my unit, the attending should be in the INTENSIVIST GROUP! Oh my god. All the rage ever. I feel like good hospitalists are few and far between... it's all the crappy ones that stay on the night shift in my hospital. One is famous for everything being "very dangerous" - "Patient ees very seeck, very septic, room air, BP 120/85, needs ICU bed stat!!!!"

It's like lady, you just took the code bed. What are we supposed to do if somebody actually CODES ON THE FLOOR?! Is one of us supposed to go up to the floor and roll in ten million IV pumps, a ventilator, and an Arctic Sun into one of those miniscule med/surg rooms to take care of the patient???

Oh god. Some of our the hospitalists are okay, but there are some I wouldn't trust to keep a cockroach alive.

I feel for your situation. Our Intensivists are very picky about what they take. They'll come look at a patient and decide in a quick minute that the patient can go to the floor and we can just send a sticker to rapid response so that they're aware of the patient and "can go hold the floor nurse's hand for a little while" (intensivists words, not mine). I get the struggle that the floor nurses have, with so many patients and the fact that today's med surg can be like yesterday's ICU, and today's ICU is full of people that would have gone to yesterday's morgue; but I also understand that we are a 300 bed hospital that only has 15 ICU beds.

Specializes in Emergency Department, ICU.
Long time lurker, firs time poster :) decided to bite the bullet...

...where I work, I also feel like a patient has to be borderline arresting to receive some tube therapy - like that oxygen saturation of 67% taped to their forehead isn't accurate / ABG pH of 7.04 is all just for show. Yikes!

First, welcome!

I feel like it's a lot harder to get a doc to intubate a patient if that decision isn't made immediately upon their arrival to the hospital.

Specializes in CVICU CCRN.
There's a large portion of me that never grew up and I'm not ashamed to admit it. :)

I feel like that's every hospitalist ever. My ICU isn't closed, so the hospitalists can admit to us, and I just want to throttle every single one of them. They always just want to sit on the patients before they make any decisions. I had one go unresponsive with an O2 sat in the 70s on 100% BiPAP before one of them agreed to tube my patient. I thought the guy was going to have to arrest to get a tube. If a patient gets admitted to my unit, the attending should be in the INTENSIVIST GROUP! Oh my god. All the rage ever. I feel like good hospitalists are few and far between... it's all the crappy ones that stay on the night shift in my hospital. One is famous for everything being "very dangerous" - "Patient ees very seeck, very septic, room air, BP 120/85, needs ICU bed stat!!!!"

It's like lady, you just took the code bed. What are we supposed to do if somebody actually CODES ON THE FLOOR?! Is one of us supposed to go up to the floor and roll in ten million IV pumps, a ventilator, and an Arctic Sun into one of those miniscule med/surg rooms to take care of the patient???

Oh god. Some of our the hospitalists are okay, but there are some I wouldn't trust to keep a cockroach alive.

I just learned that we have damn good hospitalists lol We take ICU overflow sometimes (non vented but pressors) and our hospitalists and intensivists work really well together. Our hospitalists don't direct admit to the icu though - and our intensivists will also come chat with us to evaluate a patient for placement. I don't know that they do that with all floors however - we are very high acuity for a step down unit and our ratios and autonomy reflect that.

Just had the most awesome cartoonesque image of you rolling in to one of our semi-private rooms on the regular floor with with 6 triple pumps, the Arctic sun, all the ancillary crap, and ecmo trailing behind. Not laughing *at you* per se.... But it was a pretty funny cartoon. ;)

Specializes in critical care.
I feel for your situation. Our Intensivists are very picky about what they take. They'll come look at a patient and decide in a quick minute that the patient can go to the floor and we can just send a sticker to rapid response so that they're aware of the patient and "can go hold the floor nurse's hand for a little while" (intensivists words, not mine). I get the struggle that the floor nurses have, with so many patients and the fact that today's med surg can be like yesterday's ICU, and today's ICU is full of people that would have gone to yesterday's morgue; but I also understand that we are a 300 bed hospital that only has 15 ICU beds.

HOLD THE FLOOR NURSES HAND?!

I am the floor nurse who gets the crappy "ICU doesn't have space" patients. If you think I need my handheld and absolutely nothing else from you when I call a code, you go ahead and stay on your end of the hallway. I know how NOT to code a patient who doesn't need to be coded. It sucks to sit on those people all night long knowing there is no one in the building capable of solving the problem that got dumped on me. Night shift sucks this way. I know how not to fill up your precious beds. When I call you, it's not just because I feel a little nervous.

Handholding! HA! If only! We've got 9 ICU beds with 1:1-2:1 staffing which means we usually don't have enough staff to cover that 9th bed. That intensivist is a jerk.

Specializes in Emergency Department, ICU.
HOLD THE FLOOR NURSES HAND?!

I am the floor nurse who gets the crappy "ICU doesn't have space" patients. If you think I need my handheld and absolutely nothing else from you when I call a code, you go ahead and stay on your end of the hallway. I know how NOT to code a patient who doesn't need to be coded. It sucks to sit on those people all night long knowing there is no one in the building capable of solving the problem that got dumped on me. Night shift sucks this way. I know how not to fill up your precious beds. When I call you, it's not just because I feel a little nervous.

Handholding! HA! If only! We've got 9 ICU beds with 1:1-2:1 staffing which means we usually don't have enough staff to cover that 9th bed. That intensivist is a jerk.

Yeah, we share similar thoughts there. It's tough because we don't have a step down unit of any kind, so they're either ICU or they aren't.... and that's rough on the floor nurses who get a bunch of super sick patients that should have at the very least been step down.

We had someone sent us who had been hyperventilating for hours. Came to the floor, no intubation, not one but two doctors didn't question this. No ABGs, no intubation... Real head scratcher. First thing we did was get ABGs. CO2 was 5. Off to the unit he went. Some things just leave you wondering - what the Samwise Gamgee were these people smoking?!

:eek:

Specializes in critical care.
:eek:

Yeah... That's about the face my CN and I were making. His MD (private practice) had arrived on the floor to do his notes but hadn't come in the room. We didn't know he was on the floor. When I received report from the ED RN, she only said that the guy was anxious. THAT WAS MY ENTIRE REPORT. He literally could not stop hyperventilating. It was physically impossible. I'd never seen anything like it ever. His BiCarb was through the roof ungodly high. This guy had a significant medical history that made everything make sense once we got things figured out.

Anyway, since we didn't know the MD was on the floor, CN and I did some quick assessment orders that we knew were above our paygrade but were one of those, "this guy's gonna stop breathing right now and the doc will waste time wanting this stuff anyway". After ABGs resulted, MD walks in the room before we could even call him. "Hey Dr. YouScrewedUpBig, we just ordered x, y, and z, and his ICU bed is open now, wanna come?" That poor doc looked horrified. Honestly, he's normally wonderful. I'd never seen him miss something so blatant.

Specializes in ICU.
HOLD THE FLOOR NURSES HAND?!

I am the floor nurse who gets the crappy "ICU doesn't have space" patients. If you think I need my handheld and absolutely nothing else from you when I call a code, you go ahead and stay on your end of the hallway. I know how NOT to code a patient who doesn't need to be coded. It sucks to sit on those people all night long knowing there is no one in the building capable of solving the problem that got dumped on me. Night shift sucks this way. I know how not to fill up your precious beds. When I call you, it's not just because I feel a little nervous.

Handholding! HA! If only! We've got 9 ICU beds with 1:1-2:1 staffing which means we usually don't have enough staff to cover that 9th bed. That intensivist is a jerk.

I don't blame the floor nurses when stuff goes wrong with their patients, generally - the ratio on the floors at my hospital is 1:8, and I can't imagine how you'd know anything about what's going on with your patients with a 1:8 ratio. Especially if the one slowly decompensating is the only one not on the call bell and the other seven patients want their pain meds, want to get up to pee, have family members in your face asking questions, etc.

Besides, I get my brain scrambled up and have to look at my report sheet to give report in the morning when I have three patients. I can't imagine keeping everybody's history, current CBC and BMP results, current whatever else results in my head if there were eight sets of results to remember. I don't know how anybody does it, really. I give major props to the floor nurses, and I'm usually one of the first people to say something when our intensivists/other ICU RNs make that comment, because I hear very similar things very frequently, too. Most of the people making those snide remarks have never taken care of eight patients, though, so they have no room to judge.

I will say, though, we have well over 100 critical care beds between our five ICUs and three stepdown units (60+ of those are actual ICU beds), so we are usually pretty good at keeping the really sick ones off the floors, so having a true critical patient is a frightening, paralyzing event for our floor nurses when it does happen.

Specializes in Emergency Department, ICU.
I don't blame the floor nurses when stuff goes wrong with their patients, generally - the ratio on the floors at my hospital is 1:8, and I can't imagine how you'd know anything about what's going on with your patients with a 1:8 ratio. Especially if the one slowly decompensating is the only one not on the call bell and the other seven patients want their pain meds, want to get up to pee, have family members in your face asking questions, etc.

Besides, I get my brain scrambled up and have to look at my report sheet to give report in the morning when I have three patients. I can't imagine keeping everybody's history, current CBC and BMP results, current whatever else results in my head if there were eight sets of results to remember. I don't know how anybody does it, really. I give major props to the floor nurses, and I'm usually one of the first people to say something when our intensivists/other ICU RNs make that comment, because I hear very similar things very frequently, too. Most of the people making those snide remarks have never taken care of eight patients, though, so they have no room to judge.

I will say, though, we have well over 100 critical care beds between our five ICUs and three stepdown units (60+ of those are actual ICU beds), so we are usually pretty good at keeping the really sick ones off the floors, so having a true critical patient is a frightening, paralyzing event for our floor nurses when it does happen.

You hit the nail on the head; the only difference at my hospital is like I said, we have a little over 300 beds and only 15 ICU with no step down. Unfortunately our floor nurses can get some pretty sick patients that don't qualify for ICU (often the intensivist is in our ER with multiple evals and only enough room for the sickest patient in the ICU- it's hard to convince them to put anyone who doesn't have a tube (or at least continuous bipap that is also otherwise sick) in an ICU bed. It's a struggle. I wish we had a stepdown unit that also could serve as an admission unit for patients waiting for an available floor bed.

Specializes in Emergency Department, ICU.
"Hey Dr. YouScrewedUpBig, we just ordered x, y, and z, and his ICU bed is open now, wanna come?"

Can we start using this nickname in real life? hehehe

Specializes in critical care.
Can we start using this nickname in real life? hehehe

Do it!!!! Feel free to add numbers at the end as needed.

Looks like I don't need to go dress shopping after all. [emoji20]

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