11.16.2008

Two admissions, two emergencies.

Another 12-hour shift. I'm gradually running more and more of the show. The RN supervisor working with me today stepped back and let me make a lot of my own decisions, and spent a bit of her day in the chartroom putting together in-service teaching modules for the other nurses. It was a busy day, even with the other RN supervisor helping me out with paperwork and prompting me occasionally to start or focus on certain projects.

At breakfast-time, the fire alarms went off. A little red light flashed angrily on the supervisor's panel. I imagine the panel made a sound, too, but it couldn't be heard over the deafening wail of the fire klaxons.

It was quite a sound, it seemed to cover a very wide frequency range, and caused interference patterns with the other alarms that were simply staggering.

The bright side of this was that I got to learn what we do when the alarm goes off. Clear the hallways, close all the doors, account for all the residents, etc. I helped the Lead CNA sweep the rooms and reassure the residents. The funny scottish one was on again today, I love working with her.

It took about 10-12 minutes for a uniformed firefighter to enter our facility, and he spent another 5-10 minutes puzzling over our supervisor's panel trying to figure out how to get the alarm to stop. Even after the fire klaxons went silent, all the egress alarms were still going off, and it took another 20 minutes or so for them to figure out how to turn -those- off.

As it turned out, someone had just burned some toast. Fortunately the fire alarm debacle didn't disrupt our plans too much, I grabbed the treatment kardex on the rehab side and used the treatments as an excuse to check up on the residents and examine them more thoroughly.

I had two admissions today, which was a good way to get faster with them. One was an easy knee arthroplasty. While I was giving her the head-to-toe admission workup, one of the CNAs walked in with the CNA admission packet. When I told her I was doing their admission, they said "hey, great!" and walked out of the room, leaving behind the CNA admission packet. Somehow she got the impression I was going to fill out her 5-page admission packet after I was done with my 20-page packet of documents. She sauntered in later and did her work, since I was "slow". Funny.

The second admission was for a head laceration secondary to a fall without loss of consciousness. The night shift called an ambulance for her after she triggered the emergency alarm in her apartment in our retirement community. It took even longer because she carefully read each document I handed her to sign (which is good). Each document triggered a lengthy rambling conversation (which was also good but time consuming).

We sent a resident out by ambulance with a blood pressure of 200+/100+, irregular heart rhythm (my money was on 2nd degree mobitz II block but no one did an EKG and our machine is broken) and unresponsiveness. Oh, and he was satting 82%. This person is one of our long-termers, dementia, ETOH, behavior problems. He continued to drink heavily as an elder. Now, less than 20 years away from his centennial, transient ischemic attacks of the brain had left him unable to do much of anything but eat, soil himself, and call out for help throughout the night.

At the emergency room, they simply diagnosed him with cellulitis (which he had developed in an extremity he as given a flu shot in) and sent him right back with a nonsensical antibiotic order (Keflex IV? Umm, no). They treated him extremely conservatively because of his DNR status. Once his vitals stabilized they just shipped him right back to us, no EKG or anything. The ED physician even went so far as to say that there was no point in doing anything else because the resident's a DNR. We disagreed with this, obviously, since he seemed to have treatable medical issues.

Once he came back we contacted the MD on call for us for orders. He was pretty pissed about the quick turnaround the patient experienced (they were only out of our facility for a few hours) and rattled off some orders, including an antibiotic that isn't cleared renally, which I dutifully jotted down. I placed a foley catheter (with a Coude tip to make it past his hypertrophic prostate), made him as comfortable as I could, and turned my attention to the rest of the unit.

I had spent a lot of time with this resident in the past. His room is right near the nurse's station, and he would constantly cry out at night. Most of the rest of the staff, used to his constant cries for attention, tended to tune him out. Being on orientation, I found myself with a lot of extra time to meet patient requests, so I spent a lot of time sitting on the floor next to his bed, reassuring him.

His conversations would always start with "Help! Help! Nurse! Help me please!". I'd sit down next to him and figure out what he wanted. Sometimes it was help using the urinal, sometimes it was a mouthfull of water, sometimes it was ice cream or an extra blanket. Occasionally he would say things like

"I need...I need you to be my friend. I need your friendship".

I'd reassure him by telling him he's my friend, then he would say

"No, no, you don't understand. I need your friendship 24 hours a day!".

No matter how often I explained to him that he's safe and that we're taking care of him, he would always plead with me to stay, saying he was afraid of falling out of bed and hurting himself (his bed is lowered with mats on the floor). Eventually I would excuse myself, promising to return in a set amount of time (this is what I use a chronometer for, among other things).

After he got started on PRN risperdal (an anti-psychotic), his sentences would get a little longer. The last words to me before I found him obtunded and crashing the next day were

"I need you...to help me...get out of bed...so I can dig a hole in the ground"

"There's no holes to dig here, Captain, you're in the rest home."

"I...understand that."

"What do you need to dig a hole for, Captain?" (We all call him captain, not sure why)

"I'm...not sure"

And so it would go. The director of Nursing stopped in briefly after the fire alarm incident, and she counseled me to give the Captain (in the event he appeared to have passed) a good 20 minutes before pronouncing him Dead. Apparently he went pulseless for a good 20 minutes in one of the common areas a couple weeks back. One of the LPNs gave him a light sternal massage and he went right back to Baseline. Wild.

After my shift I sat and pondered over my small, lineless moleskin notebook where I jot down notes about the residents for me to follow up on during the next shift. I brainstorm some consults and interventions for one elderly patient with a new ileostomy who's being discharged this week and still isn't changing her appliance independently. An elderly Japanese man just started eating in the common area, but I have some psychosocial concerns with him, he always eats alone. One of my favorites, a former professor of mechanical engineering with advanced dementia (tries to dissassemble everything in sight unless I give him blocks to play with or towels to fold) might have caught C-diff and I had to leave the collection of a stool sample for the next shift because I didn't get one.

Writing these notes are cathartic, because after I'm done, I don't -have- to think about it until my next shift, but if something comes to me I can always just jot it down.

On the first page is a quote from a Chuck Palahniuk novel. "Losing all hope is freedom". It appeared in the magickal notebook my intuitive/tarot/reiki friend was showing me after she got back from the Omega Institute. I copied it into my own notebook out of...I dunno...a sense of connection with her maybe? She cares for her elderly grandparents at home, we share a lot of the same interests, and she resembles someone who was very dear to me, so I tend to value her input, which tends to be wildly synchronistic at times.

Two hours after my shift, I wrote one last entry under the heading "Captain".

"Death may be imminent."

And under that,

"Wait 20 minutes before prounouncing death."

Then I ordered a beer.

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