I started the night shift – So part of this recent crisis may be related to my simultaneous insomnia/hypersomnia I have been suffering as of late.
Part of the crisis may be related to my chemistry- small bits of anxiety and melancholy that have been part of my personality since childhood.
Most of this crisis is directly related to my being asked to manage a TOTALLY UNREASONABLE patient load last week and failing miserably at the task and leaving the hospital feeling like a worthless failure.
We have this small room in an obscure corner of the ER called the A-1 room. It’s physically isolated from the rest of the staff and has 6 curtained-off patient areas. At my hospital, 6 actual patient care spots means 12-15 patients are crammed in on a busy day. This room is a nightmare for a new nurse because there are no other nurses or doctors around to ask for help if you need it. you can’t really leave the room for too long because you are the ONLY hospital staff member there watching all 12 patients. On a day when everyone is stable, great. But on a day like I had Wednesday, you are held captive in this tiny, stink room, brimming with patients. To make matters worse, you have nowhere to turn when you have questions about, say, your alcohol withdrawl patient who is bleeding copiously out of his ass. . . . .
The shift started innocently enough -three patients endorsed to me from the night nurse (it was one of my left-over day shifts before the permanent move to nights).The morning lulled me into a false sense of security, I even took a breakfast break! I spent some time cleaning up the room, which on reflection, was such a joke since, when I left that night, the room looked like a refugee camp with bodily fluids literally smearing every wall and floor surface.
When the night nurse left, she mentioned, as an afterthought: “Oh and this ETOH [ER slang for a drunk] had some blood on the back of his pants this morning but I looked at his butt and there is nothing there. I should have checked his vital signs sooner that morning, but it is so easy to get lulled into this false complacency with the ETOH patients. Sometimes you just ignore them for hours because the majority are there to sleep it off and nothing else. Once I did check his vitals, I should have been way more on top of the fact that he was tachy [fast heart rate] and hypertensive [high blood pressure]. All these should have been red flags. Come on nursing school!
(chronic drunk) = (liver problems) = (bleeding problems) = blood on pants!!
or
(chronic alcoholic) – (alcohol) = alcohol withdrawl = unstable vitals signs!
For the majority of the morning, I was just happy the drunk was sleeping and not giving me a hard time. I didn’t even bother to look at his lab work [stupid, stupid].
So of course, as the day wore on, he became sicker. Agitated, delirious, more hypertensive [220's over 110's], more tachycardic [140's, 150's], trembling. HOW DID I NOT SEE THIS COMING?? What do drunks do when they stop drinking? They withdraw!
He started requiring Ativan every 10 minutes for a couple of hours, which is a HUGE time waster running to another room, logging into the narcotic machine, drawing up the med, getting the doctor to push it, etc. Now do this every 10 minutes. Labetalol every 30 minutes to keep his pressure down, but not tooo low because there was some sort of bleeding going on, as I will explain momentarily. Firm two fingers on his forehead coaxing him to lay down every 20 minutes as he agitates his way off the stretcher and on to the floor, tethered around the neck by his cardiac monitor wires.
And then, the icing on the cake: a bed full of melena and some bright red blood mixed in for fun. Melena is an awesome mix of poop and blood put forth by patients with GI bleeds. It stinks beyond your wildest nightmares and this guy started leaking it out with no regard for MY well-being. Upper GI bleed, lower GI bleed. I don’t know. Maybe both. Of course, while floating in a sea of his own feces, he also ripped out his IV so as to better introduce E.coli into his bloodstream I guess. Changing his sheets was a monumental task as he was wholly unable to follow any directions and just laid there, alternating between flaccidity and an Incredible Hulk-like strength as he batted me away, demanding freedom from his poop-smeared prison.
So this guy could have kept me busy ALL day had he been my ONLY patient. Unfortunately, as the day wore on, the triage nurses just kept bringing me patients, faster and faster until my room was maxed out with two patients per curtained space and a few laying in the hallway. The room seriously looked like a refugee camp.
Not only was I full, but, for whatever reason, that day had been dubbed by god as a national holiday: “Old, Immobile People Pooping Their Pants Day.” I actually have no qualms about changing diapers/soiled beds. I’m good at it, I have a system, and the old people are usually appreciative, which makes me feel good. But, by myself, in the most hellishly small, NON VENTILATED room in the hospital, while trying to simultaneously care for 11 other patients? It starts to really break you down when triage gives you your FOURTH full diaper. One woman’s load was so retched smelling that a housekeeper who came in to mop actually started dry heaving into the garbage can and then ran out. And there I was, elbow-deep.
The day continued for 12 hours of misery. By the end, I was just walking around bleary-eyed, dropping tears here and there, and both praying for and dreading my relief nurse. I am, unfortunately, a little obsessive-compulsive and a mild perfectionist, especially when it comes to work. When my relief nurse takes report from me, I like to hand over a perfect board [group of patients] This means there are no tasks left to be done and every patient is worked up completely, fed, pain-free, and aware of what is going on with their case. I like to have all my ECG’s done and scanned into the computer. I like to have everyone with an IV and bloodwork already in the lab.
So when my relief came in at 7:30 PM, I was horrified that I barely even knew the chief complaint for at least 3 out of 12 patients. For example, 90 year old female, here for weakness and refusing to eat. Rightly so, the nurse asks me, “ECG done?” and I had to admit, shamefully, “No.” I had just forgotten. I mean, if anyone needs an ECG, it’s this lady. She’s old. Obviously going to be admitted (which requires an ECG if you are over 60) and I never thought to do one. Another lady had the worst headache of her life with vomiting and, to add insult to injury, she was an LPN upstairs on one of the floors. She should have gotten some form of VIP treatment – at least a “Hello” and a quick work-up. I hadn’t even seen her face yet, four hours after she arrived. She had been waiting four hours and hadn’t seen one ER employee after triage! The room was full of old ladies and elderly men for whom I had done NOTHING. Every single patient I presented to the night nurse went like this:
Night Nurse: Did you do __________?
Me: [sinking lower into the floor] No……
I stayed for an hour and a half after I was supposed to go home, just to help her get some of the bullshit administrative stuff done that I had ignored all day. She was thankful and it made me feel about 1/100th better but I still went home a nervous wreck.
I got home and John tried to hug me, which resulted in my pleading with him not to touch me and subsequently crumpling to the kitchen floor wracked with sobs. I mean, how many people’s jobs leave them sobbing on the kitchen floor in the fetal position? I didn’t sleep for my two days off after that shift, plagued by nightmares that the lady with the headache actually had a cerebral bleed and was now intubated with a poor prognosis – all because of my inability to juggle my patient load effectively and prioritize my patient’s needs. I just sat on the couch, staring at the wall and turning the TV on periodically because it helped me feel numb and stopped me from thinking about my failures as a nurse.
Third day. I had to go to work. I talked to some of my co-workers and, for the most part, they helped pick me up out of my funk by assuring me that, Yes, this shit happens. One doctor, in particular, seemed to honestly understand what I was talking about. He confirmed that, Yes, sometimes you fail. Sometimes you have bad patient outcomes and you know that, in part, it happened because of a mistake you made. Sometimes, the nature of the system is to overload you to the point where you can’t deliver optimal care. He told me it was good that I care this much and, mostly, I just need to get back on the horse. And he was right. By the end of the day, I looked totally frazzled and psychotic from 48 hours with no sleep, but I felt a hundred times better. I had delivered great patient care competently and somewhat effortlessly. I got home and I slept, interrupted by one quick nightmare only (of course about the lady with the headache). I worked another shift and felt even better.
About four days later, I ran into the nurse who took report from me that night. I asked her if she remembered the shift. She said “Of course” and complained that the room was heinous all night long. I asked her if anyone died and she laughed and said “No, of course not.” I wasn’t really joking. Finally, I asked her about the lady with the headache. She paused and tried to remember who I was talking about. . . “Ooooh! That lady did have something wrong. I can’t remember what, but her CT scan showed something. Yeah, she was sick.”
Damnit. Well, this time, I was able to identify that the patient was sick. In the ER, that is actually an important skill and not easy to learn. You may have a patient screaming and writhing next to someone who is silent and sweaty. A lot of the time, the silent, sweaty patient is way more sick, but the screaming patient is hard to ignore. As a new ER nurse, it’s easy to get caught up in the dramatic patients and forget the truly sick, quiet ones.
My hope is that, next time, I will not only identify the sick ones (great, I can tell you’re sick), but ACTUALLY HELP THEM too!
