Wednesday, May 23, 2007

Frank Red Blood

Isn't frank red blood sort of redundant? Isn't the joy of using lingo that you don't have to explain what you mean within the lingo?

As of yesterday, I have spent exactly 21 hours providing patient care. I'm still terrified, and I'm amazed at how much I've learned in those 21 hours.

  • Keep stethoscope with me at all times, unless my patient of the day is on contact precautions, then leave steth in bag and use the one draped over the cuff in his room.
  • I am a lot better at taking manual blood pressures than I thought I was. I am 6000 times better than I was in January.
  • Do not bring the linen hamper into the room with me - outside the door is fine! A linen hamper, two adults, an iv pole, a wide door, and a hospital bed in a five foot square area = disaster. It was like the Three Stooges in there while I was attempting to assist a patient out of the room to do a lap around the unit.
  • Put on the gloves before you go in. You'll never regret having them, but you may regret not having them.
  • I interacted with a lot of genitals on my first couple of days. This is normal. I will get better not staring or feeling embarrassed on the patient's behalf. Genitals are normal.
  • However, scrotums the size of my head are not. Talk to someone about possible interventions. This kind of edema may be common with a man who is largely immobile and had massive abdominal crushing injuries (although I blithely flipped past the picture and description in my Health Assessment book, thinking that I would never see it!), but it's not okay. Get a sling! Be gentle, even though it's heavy! It's also normal to have recurring dreams about lifting a five pound scrotum. Not pleasant, but perfectly normal.
  • It was wise to go to Eckerds and buy a Timex with a second hand at 9pm before clinicals at 6am. Very wise. It would have been wiser to get one when they recommended it in January.
  • It was not so wise to check out a movie after leaving Eckerds and stay up until 2430 watching it. five hours of sleep is not adequate - I would like a stress-reduction/sleep aid that doesn't take so long.
  • Bring cliff bars for snacks - one can eat them and maintain a sense of sterility. Picking up macadamia nuts from a gladware container with the same fingers that (although gloved) just wiped poop off the floor and handled a JP drain of blood and pus is not cool. Soap can't make me feel clean.
  • Stop running. Take a deep breath. Go pee, even. Say, I'm concerned about... when it's clear that I am concerned. Those words aren't going to freak anyone out more than my wildly darting eyes and heaving resp rate and flailing arms.
  • hardboiled eggs are 51 cents in the cafeteria, which opens at 0630. Go get one each morning.
  • Cleaning up poop from patient and bathroom and sheets without getting any on my white scrubs is an excellent way to boost my confidence!
And another list of reminders that is going on a cheat sheet in my pocket.
  • I am, at this point, support staff to the patient's caregivers.
  • I am providing care directly to the patient and I am responsible for doing that competently. However, I am not responsible for the overall, eventual success of the patient's recovery.
  • I am not expected, nor required, to bring all of the knowledge I have amassed into every interaction with a patient. It will flow more easily once I have figured out where to put my body, what to do with my hands, and what kinds of things are appropriate to say in certain situations. I am in a BSN program, in the very beginnings of a BSN program, but not a BSN prepared RN.
  • I am responsible for making a plan, implementing my plan, and evaluating the success of my plan. My plan is limited to the things that I know I can do, and that my clinical instructor has told me I can do, and that the staff nurse responsible for that patient is okay with me doing.
  • I can't make anyone get better. I can't even make them want to. I can pay attention to what they do want.
  • I can try to keep myself calm and centered, open and aware, and empathetic.
  • I will have varying levels of success with any plan, even the plan to take deep breaths and go pee, depending on a thousand variables.

Everything went pear-shaped for me at the end of the shift today. I had a good morning, overall, remembering to eat my snack and drink some water, and cleaned up loose stools on patient and bathroom expertly in my opinion. The patient I had last Wednesday, the guy about whom I spent most of the weekend consulting and debriefing with various expert nurse friends, was transported to a nursing home closer to his home. The music therapists were there with mandolin in hand as he was wheeled away and the combination sent me to the staff bathroom to cry.

My patient today and yesterday (post-Whipple two weeks ago, went home a few days ago, came back Tuesday morning because of a spiked fever and abd pain) had a JP drain* placed yesterday afternoon in the area that his surgeon noted as the most likely abscess** point. The bulb was filling with serosanguinous fluid when I came in at 7am. The nurse told me that it needs to be kept less than full or there's no suction and therefore no drainage. I watched her empty it and flush it at 0830. Document 50mL from JP drain on the intake and output form. At 1015, I emptied it with another student in the room. I learned that I should make sure I have a flat surface nearby to put the cup that I was pouring the fluid into since I had to hand it to the other student or try to grow a third arm. Document 90mL from JP drain for I&O.

1145 - go into my guy's room to do vitals and a noon assessment. Realize that the bulb should be emptied. Empty it, alone, but competently. Note 85mL from JP for I&O charting. Continue with vitals and assessment - point your toes, what's your name, what day is it, shine a light in your eyes, listen to your chest and belly, make my dumb joke about how you still have heart and lungs, worry a bit when patient responds that he doesn't have a gall bladder anymore, recover quickly with a comment that gall bladders don't usually make much noise anyway. Nervous laughter. Fine.
1155 - I'm done with vitals and assessment. I dumped the cup with drainage from JP drain, rinsed out cup with showerhead thing on the toilet and congratulated myself on not splashing myself. I was standing outside room charting and the wife says he's having some pain and wants to get out of bed but the bed's too high. Oh shit, I think, how many times did we say and hear that you always leave the client's bed low and locked, side rails up x2, call bell in reach?! I come in, lower the bed, and place myself in a wide stance at bedside ready to assist him to the bathroom. We've done this a couple of times already, I feel okay. My guy is pretty mobile, but I like to know that I'm there because of the fear that I'll think he's fine to ambulate around the room, and he yanks out a line, or gets lightheaded and falls.
I look down, and that JP bulb that was empty 10 minutes ago is full of frank red blood. I start mentally gasping and phrases like "bleeding out" and "surgical placement sutures dislodged" start spinning in my head. I ask the wife to call the staff nurse I'm working under, because I don't want to leave the bedside to go get her***. I get patient to toilet, because he was having lower abd pain and thought it might be gas and wanted to sit and try to pass it. He reports no lightheadedness but some nausea. I explain to the staff nurse about the bulb filling in 10 minutes and the change in color and the pain and she is nonchalant. She says she'll look when he comes out of bathroom. I don't know if I should wait outside of bathroom or what. I am trying to be clear in my description, without showing that I'm freaked out. I realized later that what I was doing was trying to scare the staff nurse into doing something, but not scare the patient or his wife. She responds as if she didn't really understand that the type of drainage has changed to bright red blood, and the rate of filling has increased from 80mL in two hours to 100 mL in 10 minutes.

1200-It seems like I should be pushing the Code button, like I could say the right combination of words and she would just leap into action. This is not true. She moseys away, and I go find clinical instructor to explain situation. Clinical instructor agrees with me that it's important, and has me stand with staff nurse while she calls and tries to get a physician to come look at patient. I can tell within10 seconds that whoever the nurse is talking to is not coming, she's weaseling around, trying to sneak up on the problem. I did this even when talking to her, but I thought it was because the patient and wife could hear me. Where does this sliding around language come from?

1210 - resident told staff nurse that he was in clinic, and to call the PA. PA is also not available. Staff nurse gets charge nurse to come look. By this time, bulb is filling again, with a big gelatinous clot taking up much of the bulb. Staff nurse shows charge nurse, patient looks green to see all this blood, and discussion of clots. Charge nurse says, yes call the house officer. I get a chance to offer my line that I emptied the bulb at 1145 and it was full of this type of drainage at 1155. I wonder what a House Officer is.

1215 - Apparently, house officer means someone who struts, makes zero eye contact and doesn't speak to nurses. I'm standing the room, having delivered ice water, when he marches in and starts talking. He picks up the bulb, and starts talking immediately about "old blood" and "pancreatic juices" before he's even really looked at the the thing. I start to say, "But I emptied this bulb at 1145 and it was full ten minutes later". and then i start to really worry - what if I'm responsible for this problem because of how I emptied the drain? I also get all stage-fight-y and worry that he's going to spin on me, and not listen, or be snotty because I'm speaking to him. Shit! Didn't I swear that I wouldn't buy into this idea that even as students, we are not to be cowed by the idea of speaking to physicians?! I left the room, but stood in the hallway and looked terrified. The charge nurse made eye contact with me, and said, get back in there, you can totally be there! I stood in the door and started to speak and then froze again. The patient and his wife were clearly confused and I didn't want my questions to make things worse for them. Also, the staff nurse for this patient was in the nurses' station, seemingly unconcerned by the consult with the House Officer, and I thought that meant that I should be unconcerned as well.
He spoke in phrases that seemed to have no linkage - like a two year old talks in telegraphic speech and you have to fill in all the grammatical cement. He said something about leakage from the pancreas because of the whipple, and that the fact that my guy had had radiation and chemo before the whipple made this more likely, and that the "old blood" was from the surgery (but did he mean the whipple, because that was two-three weeks ago, and is it still supposed to be bleeding like this?) He said that he's going to give a drug to stop the activity of the pancreas (which my clinical instructor referred to as "challenging the pancreas" when I talked to her later. He wrapped up with something about "we'll get this emptied out, you know the whole bulb just comes off and we'll get it the clot out of there" and patted him on the knee and was gone.
As if we hadn't just tried to empty it. As if this was just the accumulation since 8am, not since ten minutes ago. As if there was no indication that anything was wrong - when what I was concerned about was an emergent situation, like in the last twenty minutes, not since breakfast.
House Officer never communicated directly with Staff Nurse. WHY? Why didn't he ask her to clarify what was concerning to her if he was soooo obviously unconcerned? Was I concerned only because this is the first JP that I've seen/cared for? Is it normal for them to suddenly begin filling in 10 minutes, when they've been filling in two hours since they were implanted 12 hours ago?

Then, it's time for us to leave the unit for our conference and math test on medication dosage and IV drip rates. I check in with nurse and patient to say goodbye, feeling like not everything that could be done has been done, but completely unprepared to do anything more myself. The nurse is more annoyed that I didn't get the man a bath this morning, though I did get the sheets changed.
I explain situation once again to Clinical Instructor, in a final attempt to get some closure. CI says that I did a good thing in immediately noticing, and that as long as I told the staff nurse everything I did and noticed, I'm good, and since I witnessed her take action on the situation, I'm clear. "But!" ,I want to whine, "it's not Fixed! I don't know what they're going to do! The guy in the blue scrubs was talking about how it's not serious because his heart rate and blood pressure aren't dropping, and I didn't check his pulse after it started filling like that. What if it's something serious, and they don't catch it? What if something bad happens after I leave? "

What if something bad happens after I leave? This is the thought that I leave with. Is this the thought I will leave with at the end of every shift? Does my clinical instructor have this same fear? I won't be back tomorrow. I want to know - want to call up to the unit later tonight. It's not my place. I've taken on too much of a sense of control or responsibility, I guess. But where's the line, then? What is the point that I'm NOT responsible for anymore. The thing that I can think of that I could have done better or differently is speak directly to the guy in the blue scrubs, explain in as few words as possible what I observed and why it concerned me. I have been composing those few words over and over and over again in my head. I wanted to be able to say it right so that he would do something - wanted to keep re-phrasing it so that he would leap into action. It's a horrible feeling to feel like leaping up to do something, but not having the authority or the experience or the knowledge to know what to do.

I thought I would be so exhausted that I'd fall right asleep but I ended up having to put myself to sleep last night with my art history textbook, desperate for images and words to replace today's.

*I just learned that I've been misspelling abcess all day in charting!
**A Jackson-Pratt drain looks like a little plastic turkey baster, attached to a clear tube that has been surgically placed within the body. There's a little port on the bulb like the thing that you use to blow up an inflatable pool toy and this is how you get the fluid that's drained into the bulb out. Open the port, let the fluid drip into a cup or whatever, squeeze the last bit out if you need to, maintain squoze-ness of the bulb, and close the port. The vacuum continues to suck the exudate out of wherever the other end of the tube is.
***Note to me, hit the call button and ask the unit coordinator to get my clinical instructor sent to me as well. As she says, "We'll all go to jail together since you're working under MY license."

1 comment:

"Loving Pecola" said...

I enjoyed reading this post of yours. I remember feeling like this on my first days of clinical. Everything was important, but no one else seemed to move as fast as I thought they should! Good job advocating for your patient!