mood lighting

this week, a nurse on our unit, as she was leaving her patient's room said, "is there anything else i can help you with?" to which her patient responded by grabbing her hand and placing it on his erect penis. her response, "i can't help you with that, but i surely will turn off the lights and give you some privacy!"

day off from nurse patient

for the first time in two months, i got to work today and did not have the nurse patient. she had been assigned to another nurse on my unit the two days prior and so, for his third day, it's not really fair to change his assignment. and to be honest, there was a tiny sense of relief in my heart knowing that i had one day off from caring for a very sick patient with whom i have become very close.

this evening though, her nurse asked me for assistance. he knew the patient trusted me and felt comfortable in my presence. so together we gently assisted the patient back to bed after an embarrassing mess was made. her respiratory rate had increased with the work of climbing into bed and in just moments, i could tell her health had severely declined since thursday when i cared for her last.

tomorrow, i will have the nurse patient. i requested for her to be "mine." and i'd be lying if i didn't acknowledge that in me there is a bit of worry that by tomorrow morning, nurse patient might be in the intensive care. that i may never get a chance to be her nurse again. that patients only survive so long without an immune system and with metapneumovirus, with multiple bacterial infections - gram negative rods and gram positive cocci resembling chains (that's how the lab talks about germs - crazy!).

not sure what i will find tomorrow morning, but i hope i find nurse patient in room 46... where she has been for months. and where she is "healthy" enough for my care.

manicure

when i became a nurse, i had no idea what i was getting myself into.

that's not totally true. before i went to nursing school, i volunteered in kolkata, india and saw some pretty gruesome and horrifying things. there were maggots crawling out of wounds and hiding under tissues; we played hide and go seek with tweezers for hours. and more than once i saw prolapsed uteruses hanging between women's legs (at the time, that sure confused me; i wasn't sure what i was looking at). sorry to be graphic, but it's true!

but in the US, i have not seen these things. perhaps it's because i am on oncology nurse. thankfully, we avoid maggots and uteruses in oncology. but i have seen and done some other strange things.

this week i was humbled by helping my patient with a manicure. imagine being so sick that you don't realize (or even care) that there are things under your nails even a gardener would cringe at. with delicacy, so as to avoid embarrassment, i told my patient it was time for some pampering (we HAD to do something about the poop situation under her fingernails). i filled a basin with hot, soapy water and grabbed a toothbrush (that i promptly threw out so as to NEVER be used in her mouth) so my patient could go to town. sadly, she didn't even have the energy to take care of business herself. So, i gave my first manicure. there was no polish. just 10 minutes of soaking, scrubbing, and "pampering."

some of my nurse friends and i always joke about being sick (we have to make light of the situations we see). we have promised one another that if one of us is dying, we will take care of the hairs on chins and keep lady parts clean. those two things are critical to one's dignity at the end of life. this week, i have added a new task to the important list. please, please - someone get the poop out from under my fingernails!

good day

i sent my nurse patient for emergency surgery last night. it's crazy. we avoid surgery like it's the plague during transplant. in fact, we avoid any invasive procedures... even simple ones like pricking patients' fingers for blood sugar checks. any damage to skin creates a porthole for infection to enter the system. hence, i was more than surprised! i was shocked. followed by insanely busy! when the decision was made.

within minutes of the consent being signed, i had phone calls from the OR wanting an extensive report. there were emergency platelets to order and administer to reduce the risk of bleeding. i had stat labs to draw, a type and cross to be sent in case of a need for blood transfusions. not to mention all of the other medications she needs on a daily basis that keep more than busy.

i left last night with a sense of doom. for the procedure, the nurse patient would get general anesthesia which requires intubation. with a risk of difficulty extubating (especially in someone with known respiratory issues - she has metapneumovirus, a common cold). because her body is not making it's own platelets, she is at a HIGH risk for bleeding - despite the three bags of platelets i administered. not to mention, her risk for further infection (she already has positive blood cultures causing fevers) increases with incisions and manhandling. nurse patient has ZERO immune system... and won't for at least two to four more weeks. so, in my doom and gloom mind, i envisioned an intubated nurse patient, bleeding out, and septic from infection to "greet" me in the AM.

but, to my surprise (and delight), nurse patient was a-okay this morning. aside from being pissed that her night nurse put a bed alarm on her so that every time she got up to use the commode, an alarm signaled (and it's incredibly loud), she was okay. in fact, she was better than okay. the pain caused by the infection that was drained during her surgery had decreased. and in the end, today was another busy, but good day.

keep the good days coming!

potentially lethal error

recently i have found lots of errors at work. sometimes they are minor. tums from the day before are still left at the bedside. an IV medication is hung an hour late. somebody is supposed to be NPO (nothing by mouth), but they eat breakfast. these errors can delay treatment or put a hiccough in the day. but unfortunately, i have found some larger errors lately too. yesterday was a BIG one. a potentially LETHAL error. made by a new nurse. and i can't help but be dumbfounded as to how much responsibility we have as nurses and how much potential we have to harm. i also can't get over the fact that this nurse passed nursing school, the NCLEX (our certification test), and 6 weeks of orientation on our unit.

during shift report, the off-going nurse was telling me about her night with nurse patient. i was logged into the computer, assessing her labs. when i saw a critically low blood sugar at midnight, i inquired. the nurse slowly revealed what had happened. not until minutes prior had she realized her mistake. here is what happened:

at 1926 on friday night, before i left, i checked nurse patient's blood sugar. it was 276. this is high. the night nurse said she would notify the doctor and get some insulin orders. so, i left. assuming all would be well. LESSON ONE: don't assume.

the night nurse was ordered to give 3 units of insulin. we have special insulin syringes. they are miniscule. 3 units is barely a measurable volume. however, the night nurse chose a regular syringe. instead of drawing up three units, she drew up 0.3mL of insulin. she delivered 10 times the ordered dose. LESSON TWO: use the correct syringe.

not until midnight labs did the blood sugar get checked again. at this point, the patient's blood sugar was 51. this is critical! night nurse re-checked the patient's blood sugars at 0158. the result was 60. still critical. at this point, the night nurse woke up the nurse patient and offered her juice. when night nurse asked nurse patient if she could re-check her blood sugar later, nurse patient refused. LESSON THREE: never let patient's refuse care that is for their safety. the protocol for low blood sugars is to re-check every 15 minutes until levels return to normal.

the next re-check was done more than 4 hours later at 0636. by this time, nurse patient's blood sugar had recovered. she was back up into the 200s (which according to the orders, meant she should be getting more insulin). the night nurse told me this and said she would give the patient 2 more units before she left. my response, "i don't think so. please do not touch the patient. i do not feel comfortable with your giving her ANY insulin. i don't trust your blood sugar assessment. and i don't want to give the patient ANY insulin at the moment, until we sort this mess out." LESSON FOUR: giving feedback to nurses may result in tears, but it is essential.

i took the new nurse into the medication room, showed her the two syringes, drew up 3 units and 0.3mL and asked her to compare the difference. she laughed (not quite the response i was looking for). concerned about my patient, i ended my teaching moment and decided to proceed with my day. i rechecked my nurse patient's blood sugar; indeed, it was elevated. so i told the doctor it was high but that i was refusing to do anything about it. high is better than critically low. i did not want to give any more insulin at the time. LESSON FIVE: communication with physicians is important. documenting that communication may be even more important - to protect your license. the night nurse never once documented that she notified the on-call physician of the patient's critical lab result.

until i suggested it, the night nurse was not going to write an incident report. LESSON SIX: when you fuck up, you acknowledge it. you write an incident report, not to get yourself into trouble, but to alert someone that the system is unsafe. that somehow, you were able to make a potentially lethal error. and it could happen again unless someone assesses the system and implements safety guards.

so help nurses and our potential to hurt people.

toes crossed

the cells are in! i gave a double cord blood transplant to nurse patient on friday. happy new birthday! 278mL of cells (that's less volume than a soda) were infused in less than 45 minutes. and they may potentially save my patient's life. keep your fingers (and your toes) crossed...

here's to healthier

i work tomorrow. and tomorrow is the day before nurse patient's second transplant (we call it day -1). she will be getting two doses of radiation during my shift in preparation for the double cord blood transplant she decided to get- because although the risk of failure is higher, the possibility of engrafting comes earlier than had she waited for the german donor. and my patient is SICK. she KNOWS she is sick. and i worry that she is giving up - allowing medicine to control her instead of playing an important, motivated, and determined role. she's tired. and weak. and scared. and NEEDS for this to work. quickly.

i work friday too - her transplant day (we call it day 0, a new birthday of sorts). i will be infusing two bags of precious cord blood that two generous mothers donated to the world of cancer patients. and although i have NO control over how this scenario plays out, i feel a small sense of responsibility. i have cared for nurse patient every shift i have worked since february. we have formed a bond. and if this does not work out (which i fear), i will be devastated.

in some way, nurse patient motivates me to come to work. i feel like someone needs me. she and her husband feel safer when she is under my care. and i feel proud of my job well done. on monday evening, nurse patient's husband said to me, "christa, you are the best!" my response, "i enjoy caring for _ _ _ _ _. you make me want to come to work and do a good job. i only wish you were healthier!"