Once Bitten Twice Shy
Yesterday, I had a new experience as a nurse…. I was bitten by a patient.
I was team leading (same as a relief charge nurse) & helping another nurse admit a patient to the ICU from the cath lab. He was in his 50s, had a heart attack, and the lesion was successfully opened and stented by the cardiologist. This patient was spanish-speaking (surprisingly, something we don’t see in my area of Phoenix as often as you’d think) and he was waking up from sedation very wildly – thrashing all over the bed and trying to sit up. I was holding one of his arms down, and the other nurse was on his other side, because he still had a sheath (big IV access) in his groin and if he sat up, he would run the risk of severe bleeding. We were attempting to get him to calm down, when he pulled his arm (the one I was holding) up to his face and bit my arm. I pulled away quickly and used my other hand on his forehead to keep it on the pillow.
Two more male staff members came into the room to help us physically restrain the patient (now for our safety as well as his own). We then called for security and the house supervisors to come to the room and the patient was placed in restraints and his sedation from the procedure kicked back in.
I know that there were many variables that act as excuses for this patient to act how he did (language barriers, confusion from sedatives), but there was a spanish-speaking staff member in the room while the patient was acting out and the patient was fully aware of what was going on. He knew that he was in the hospital and remembered coming to the emergency room with chest pain. If a person is awake enough to realize these things, I think there is no real excuse for actions like that. I’m sure it’s hard being in that situation – not knowing what exactly is going on and having people trying to restrain you, but to lash out and bite someone when you willingly came into the hospital for help is inexcusable.
Situations like these make me weary of getting as close to patients as we often have to. But, my two options as a nurse are to 1) attempt to restrain him and put myself in danger, or 2) let him do what he wants, which would cause a life-threatening bleed from his artery onto the bed or into his abdomen.
What’s a nurse to do?
Hasty Judgments
I made one of those mistakes that your mom always warns you against… judging a book by it’s cover. Being a nurse, it’s so easy to generalize having seen all the sights that we’ve seen. You get report on your patient who’s a smoker and threatening to leave the ER to get a cigarette (but is still being admitted as an inpatient) and you assume it’s going to be a long, argument-filled day of why she cannot just simply “step outside for a smoke”. Or, you hear in report that your patient’s tox screen was positive for cocaine and he just had a heart attack…at 30 years old. It’s sometimes very hard to have compassion for those people who have brought their medical problems on themselves while in the next bed, a sweet 72 year old is hanging on to her life without doing a single thing to harm her body (and generally the non-drug user is a lot kinder to the staff and easier to get along with for 12 hours straight).
I was at work recently, and my morning started off with one patient who had surgery the day prior and my other room was the open bed (meaning that I was the nurse open to take the emergent patient from the emergency room or the patient who was coding on the other floor). My surgical patient wasn’t doing too well- her morning xray showed that her left lung was whited out (which in her case meant that she had blood around that lung) and she needed a chest tube placed to drain the blood. So, the surgeon came in, and it took him several attempts to get the tube in because the patient had a lot of scar tissue around her lung due to a previous lung surgery and about half of a liter of blood ended up on the bed. At the same time as we were cleaning up the mess, the charge nurse came in to let me know that I was getting a patient who came in from the emergency room and I needed to call and get report. So, that was already a bad start to hearing about the patient- I was about 2 hours behind in caring for my first patient and now I had another one to admit.
So, I call down and get report from the nurse, who starts by telling me that this patient is HIV+, has hepatitis, herpes, is a current smoker, and they just had to sedate because he was screaming and rolling all over the bed. Awesome. If this doesn’t sound like a winning assignment, I don’t know what does. *sarcasm*
The patient gets to the unit, is indeed restless and complaining of a lot of pain (and in my head I’m wondering if he’s a drug user too because of the other history I had heard). So, I give him morphine and he actually sleeps for a few hours. This is the definition of nursing bliss. :)
After he wakes up, I had all of his HIV medication (that we had to have couriers pick up from other hospitals in the valley because they are so hard to come by and expensive). I got him a sandwich from the kitchen and we started talking – he was very calm and relaxed now. He told me about his past – he was a professional figure skater and lost his partner about a year ago to heart failure and has been having a rough time ever since. He had a dog at home that he was worried about because he didn’t have anyone to go feed the dog while he was in the hospital (our direct of social services ended up taking the patient’s keys and going to get his dog, with his permission of course). We talked for almost an hour and he was one of the sweetest people I had come across in awhile.
I wish that I could curb my judgments about people more easily. I was dreading my day in the morning and as I left work that evening, I had a smile on my face. It was a good day.
Hand Sanitizer- Helping or Hurting?
I’m sure that you’ve seen an abundance of the hand sanitizer dispensers everywhere; hospitals, the gym, grocery stores, day care centers, etc. But, the real question is whether these actually protect you from the dangerous viruses you see all over the news (ex. H1N1/Swine Flu). Well, sure… but only if used correctly.
Getting specific:
Hand sanitizer works when the alcohol (it’s active ingredient) dissolves the cellular membrane of the bacteria, which then inactivates the cell and does not cause a resistance to be formed to the alcohol. Washing your hands works by physically removing the germs from your hands, but this is only effective if it’s done correctly.
When purchasing your hand sanitizer, check the concentration of alcohol – at least 60% is recommended to properly disable the bugs.
Directions for use:
When used correctly, hand sanitizer needs to coat the skin 100% – it can only deactivate the germs it touches. Generally a dime-sized amount of gel will cover the hands. Rub hands together until completely dry. If hands appear soiled (dirt, blood, etc), it’s time to break out the soap and water.
WebMD goes through these 5 steps for proper hand washing:
- Wash your hands with hot running water and soap. Children should use warm running water.
- Rub your hands together for at least 20 seconds.
- Pay special attention to your wrists, the backs of your hands, between your fingers, and under your fingernails
- Leave the water running while you dry your hands on a paper towel.
- Use the paper towel as a barrier between the faucet and your clean hands when you turn off the water.
The biggest downfall of soap and water:
The steps for sanitizing are visibly easier than the steps for proper hand washing, so it makes more likely for people to use the sanitizers, which is important. If no one is washing their hands, it’s not going to do any good. We can keep small bottles of hand sanitizer in purses, cars, etc.
My personal opinion is that we should all wash our hands with soap and water whenever possible, but especially as we’re coming out of the bathroom, cooking in the kitchen, or after finishing up an afternoon of working outdoors. But, for those times when washing our hands isn’t feasible, hand sanitizer is a great alternative to doing nothing. I keep a bottle of sanitizer in my purse at all times and use it while I’m at the grocery store, leaving a friend’s house who has kids/dogs, or after touching something that makes me nervous (yes, those things are out there… have you seen peopleofwalmart.com?)
5 Misconceptions of Nurses
We’ve all heard them… those phrases that people say to nurses that people direct at nurses because they do not have any idea what we do (and my sarcastic answers). :)
- “You are so lucky to be a nurse because you get to date all those sexy doctors.” Yes, you’re right. My day at work is exactly like you see it on Grey’s Anatomy every week.
- “The nurse at my doctor’s office says…” Again with the mistaken assumption that anyone in scrubs is a nurse. The medical assistant at your doctor’s office, however capable she may be, is not a nurse. The fact that she can take your temperature, your blood pressure, and has a stethoscope does not make her an RN. Neither is the receptionist at the front desk or the phlebotomist who draws blood for your lab work. They are all vital members of the health care team and they have challenging jobs in their own right; but unless their nametag says RN or LPN, they aren’t nurses.
- “Why don’t nurses wear white caps anymore? They looked so nice.” Seriously, kids?
- “I bet you make a lot of money.” Yep, I’m set to retire at 45 and head to the south of France. Know any more good jokes??
- “My call light’s been on for 45 minutes—where were you, on the computer at the nurses’ station?” Absolutely! And while I was at it, I Googled myself and my family just for the heck of it, bought a Playstation3 on eBay, played solitaire, and searched Craigslist for leaf blower. Did you actually need something or can I get back to my desk and start my session with the masseuse?
I love my job and my career; I just wish the community as a whole had a little more appreciation for what we do.
Nursing Certification
In nursing school, I never really knew what nursing certification was, nor was I very concerned about it. Heck, I still had this beast of a test, called the NCLEX, to pass. I was fortunate enough to land my dream job in a CVICU while I was still in nursing school, so the minute I arrived, I knew I wanted to prove that I could do this- not only to my newly acquired peers, but also to myself. I quickly signed up as a member of the AACN (American Association of Critical-Care Nurses) and set my sights on gaining enough knowledge to pass the CCRN Exam (certification in critical care nursing). After a year of nursing practice, my educator enrolled me in the Open Heart Recovery class which details the process of caring for a patient in the first 12 hours after Open Heart Surgery. What an eye opener that was – so much new information that helped all the pieces fit together. I loved it! Taking care of this population reaffirmed that I was in the right place; it refreshed my commitment to my career. This boost gave me the confidence to sign up for the CCRN exam, which I sat for and passed! :)
Then, around my 3 year anniversary, I decided I was up for another challenge (and some more cool letters after my name) and signed up for the CSC Exam (certification in cardiac surgery). I found a book that many others had read & recommended called The Manual of Perioperative Care in Adult Cardiac Surgery and read it cover to cover. The book starts off by giving information on pre-op care, from both a nurses view and a physicians view, then goes into techniques for surgery which doesn’t directly relate to test content. But then it gets to the good stuff… what I do every day at work, but it gives rationale for why we do what we do, which is especially useful for some of the things that have become automatic in my daily care. I sat for my exam as scheduled and passed! It really does feel great.
Certified nurses show their community that they are dedicated healthcare professionals. These certifications are voluntary (for the most part), don’t often come with huge pay raises, and require a great deal of work. So why do it? My answer… pride. I take so much pride in my knowledge base and my ability to take care of my patients each and every day that I’m in the hospital. It also shows your employer (& your increasingly savvy patients) that you have commitment and dedication to your work. By getting certified you are going above and beyond what a “good” nurse is doing. After receiving your certification, you are required to keep up with continuing education in order to renew which keeps you abreast of the most up-to-date information in your field.
“A journey of a thousand miles must begin with a single step” -Lao-tzu (Chinese philosopher) If you’re thinking about certification, take that step. You won’t regret it.
Social Media Immersion
There were so many reasons why I originally decided to get excited about immersing myself into the world of social media (i.e. blogging, twitter, etc). My main reason was the influence that this realm could have onto the profession of nursing. I remember searching through allnurses.com years ago when I was a young, fresh face in the field. I could search through the forums and find nurses that were going through similar dilemmas, post questions about nursing practice at other hospitals, and read news that was relevant to the nursing field. It felt amazing to be able to talk to other people about anything and everything. And now here we are, in the time that social media is really coming to life. We have so many ways to stay involved at a professional level (linked in, twitter, websites, blogs, etc) that it makes it so easy to connect with other people who can relate to your workday. Have you ever come home from a long/interesting/stressful day at work wanting to tell your husband/wife all about it, only to have them zone out when they can’t relate to all of your medical jargon? Well, that’s just one of the reasons that so many of us love to turn to the interwebs.
Nurses in social media can also have an influence on the general public. Our patients are getting more tech savvy each year, researching the internet and sites like Wikipedia for information on their illness and its treatment. They are also using sites like DailyStrength.org to connect with other people with their same diagnoses and join free support groups. Nurses are able to reach out to their patients in a whole new way.
Nursing Abuse
Before this week, I really had never given much thought to this topic. I’ve read articles about it, I’m aware of the laws (it’s a felony to assault a healthcare worker), but this has never been a big issue in my nursing practice. I work in a cardiovascular ICU, which means that most of our patients are post-surgical. When patients are taking swings at you, it’s usually because they’re coming out of anesthesia and, as frustrated as we are as nurses, we deal with it and let it roll off our backs.
But, when you take care of a patient that is free of any anesthetics in his/her system, and they are not going through problems related to a medical condition (stroke, DTs, etc), there is no excuse for abusive behavior. These behaviors can range anywhere from ordering you around like a servant: “This water isn’t cold enough; get me a new cup now!”, to calling you a *insert swear words here*, to grabbing onto your hair and not letting go. To be honest with you, I’m not sure which one of these scenarios bugs me the most. They all irk me, but in different ways. They are all so similar because they all cause me to lose instant respect for the patient. I walk into my shift every morning with full expectations that I’m going to have a good day. Even when I get report from the nurse who’s going off shift and he/she tells me “Oh, bed 36 is such a pain in the butt”, I still walk into room 36 with a smile on my face and a clean slate hoping for the best.
But when the patient does something disrespectful, all bets are off. I am still a high caliber nurse even when pushed to the brink. My patients are always well taken care for, all of their basic needs are met, but it makes it harder to WANT to go into the room and check on the patient. It makes it hard to WANT to get them a fresh cup of ice chips because you see the current cup is half melted or WANT to give them a lotion backrub because you know they’ve had to lay in bed for 6 hours straight after a procedure.
I do WANT to be a caring, thoughful, hard-working nurse. Why are you making this so hard for me to do?
Nursing Humor
Laughter in the ICU is a necessity – without it, nurses wouldn’t stand a chance against the stressors we face on a daily basis. Bad things happen in an ICU…. people are sick and sometimes people die.
Often, we laugh at inappropriate things & if you’re not a nurse, chances are that you can’t fully understand how our inappropriateness is actually appropriate for our daily lives. In the most extreme example, you’ll see nurses making jokes during a life or death situation; a patient is crashing and as the nurses do everything within their power to “save the day”, they laugh & make jokes about the situation.
Get peed or pooped on at work during your workday? Talk about it during dinner… and laugh when innocent bystanders get grossed out.
One afternoon at work, we had a ScareFest set up in an empty patient room to highlight the importance of patient safety. It was a “find what is wrong here” game, with a mannequin and the whole 9 yards. We had a “used” bedpan (made with apple juice and a few small pieces of Snickers bars) and the silliness ensued. We ended with a photo shoot, including the picture on this page, which became my Facebook profile photo. I received a ton of comments, mostly in the realm of “ewwww” and “that’s disgusting” from my non-nurse friends, and comments such as “that’s hilarious” and “looks like you were having a good time at work today” from my nurse friends. I think that perfectly shows our humor as a profession as a whole.
“The ability to laugh at life is right at the top with love and communication, in the hierarchy of our needs. Humor has much to do with pain; it exaggerates the anxieties and absurdities we feel, so that we gain distance and through laughter, relief. “ –Sara Davidson
Patient Recovery
Back in April, I wrote a post in this blog about a young patient who had heart surgery, and developed ARDS (Acute Respiratory Distress Syndrome) after surgery requiring him to be on the ventilator for over a week. During this time, he was wide awake during the daytime. We developed hand signals so that we could quickly communicate the common things (wanting to turn on his side, needing some moisture for his mouth, wanting me to call his significant other, etc) and he had paper and a pen on his bed to write notes for the not-so-common things, like asking questions about his care and wanting to clarify what the doctors were telling him.
During his 7 weeks at our hospital, he was transferred out of the ICU to the telemetry floor, back to the ICU, and then to telemetry again. I had the pleasure (and pure luck) of running into this patient and his significant other in the elevator on the day he was being discharged. He was on oxygen, weak, and in need of rehab, but otherwise looking pretty good for all he had been through over the previous 2 months.
Yesterday, I was in a patient room when I saw a familiar face outside the door – it was this patient and his significant other. My jaw dropped – he looked amazing. He had comfortably walked down the long hallway to the back corner of the ICU, he had a giant smile on his face, and was wearing a portable oxygen pack. He told me about his recovery and that he’s back to most of his normal activities. He’s gained about 15 of the 25 pounds back that he lost during the illness and only has to wear his oxygen during physical activity. Just before the onset of his illness, he and his significant other were packing to travel to New Zeland where they had planned to exchange vows of commitment (a non-legal marriage). Because of his oxygen needs, they haven’t been able to go, but it is planned for next spring.
He has no recollection of being in the ICU or being on the ventilator, only vague memories of our sliding glass doors on the ICU patient rooms. As we were talking, a monitor alarm went off in the room next to us, and he said with a smile, “oh, I remember that sound too.” That’s one thing about being an ICU nurse… patients usually don’t remember us because they’re so sick while under our care. That’s okay with me though. I know everything that this man went through during his weeks in the ICU and I know that it’s better for him not to remember- he went through some tough stuff.
Seeing him walk out of the unit was one of the best feelings I’ve had at work in a long time. :)
Health Literacy
Every hospital has a routine form for the discharge instructions that is given to the patients. It’s usually a printed form, with check marks that dictate allowances on activity, diet, wound care, a list of medications, and a printed copy of educational material. But, how do we, as health care providers really know that our patients are comprehending what we are telling them? That’s the tricky part. Sure, some of it is easy… don’t drive until the physician gives you the all clear… don’t shower today, but you may take one tomorrow… etc. But what about REALLY understanding their diagnosis and medications?
I was caring for a patient who coded at home, was revived by the paramedics, brought to the emergency room, and was currently intubated, unresponsive (on her own – we were not giving any sedation), and was frequently having episodes of Ventricular Tachycardia, meaning that her heart was quivering and not pumping blood to her vital organs. So, we were defibrillating (shocking) her heart about 5 times each day to keep her alive. Generally in patients who continue to have arrhythmias requiring them to be defibrillated, we would put in an AICD (automatic internal cardiac defibrillator) that would shock them from inside their chest at a much lower voltage. But, an ethical question came into play- the patient was unresponsive and her EEG (electroencephalogram – which is a study of the brain waves) was flat, meaning that she was brain dead. If we were to put in the AICD, she would live as a “vegetable” and have no quality of life. After a few days, the patient’s husbands eventually came to terms with the situation and let her pass on.
During my multiple days taking care of this patient, I had ample opportunity to talk to the husband about their life together, what his wife was like before all of this happened, and anything else he wanted to tell me. One of the things we talked about was her aversion to medications. She had been diagnosed with congestive heart failure a few years before and was on about 5 different daily medications, including Lasix (a diuretic, which pulls excess fluid from the body which removes some of the workload from the already weak heart). Lasix has a side effect of removing potassium along with the extra fluid, so most patients who take Lasix daily are also prescribed a potassium pill to prevent the potassium level from getting too low. In the body, potassium has many functions, one of the most important being its important role in muscle function, including the functioning of the heart muscle. From talking to the patient’s husband, I found out that she had been religiously taking her Lasix because she was told how important it was, but she was not taking her potassium supplements because it made her nauseated. At that moment, it all made sense… looking back at her lab work, her potassium level was at a critical low when she was brought into the emergency room, and the lack of potassium does not allow the heart muscle to squeeze appropriately.
I gave this information to the cardiologist when he came by that afternoon, but I didn’t have the heart to tell the husband myself that all of this most likely came about from his wife not taking a supplement that she was prescribed.
I can only assume that the doctor who prescribed the potassium supplements and/or the nurse who gave the discharge instructions (if it was prescribed when she was in a hospital) did not emphasize the importance of the potassium with the lasix.
To help elliviate this problem, I would love to see hospitals routinely make follow-up phone calls to patients discharged from the hospital. The hospital would inquire about their health since being discharged, if their pain is well controlled (if they had surgery), make sure they were able to get all prescriptions filled, and go over any questions that the former patient may have. Not only does this improve patient education (discharge is often an overwhelming time as the patient is getting many pieces of new information in a short period of time), but it will also improve the satisfaction that patients feel with the hospital, showing that they are cared for, even though they are not within the walls of our faciltiy.