Off to a new home!

Yes folks, Lost on the Floor is moving. I went over the reasons in a previous post, did some thinking and realized I wanted to spend more time with my family and actually writing, rather than playing with HTML and code. I'm a nurse, not a programmer. Everything I read seemed to point my way over to WordPress. So I've set up shop over there for good.

So update your bookmarks, adjust the feed in your reader and come on down!

New Change of Shift!

Change of Shift has returned home. Go check it out over at Kim's place. Great stuff as always.

Happy reading!

Help Needed!

I have multiple problems that I am trying to wrap my head. I'm increasingly getting tired of Blogger, frequent outages, posts disappearing (or getting mangled), tedious template mods and the inability to quickly change a template/theme. I don't have to time I need to fool around the web trying to find a template I like and then taking the additional time to tweak the template and add back in all of the user modifications I've made. I'm a little bit of a design geek, but can't take the time I want to make my blog look like I really want it to, so I settle.

But on the other hand, I like Blogger as I have been using it for so long (not just here). I "trust" Google (about as far as I could throw them), but I realize that they're pretty stable (company-wise). I have my content here adn don't really want to have to shift it somewhere else (or lose it all together). And it's easy.

I want to spend more of my time writing rather than trying to cajole something into working order - I do enough of that at work. Anyone have any suggestions? Is Wordpress better than Blogger? Should I just leave well enough alone? Anyone have an idea how to fix my code so that the sidebar just doesn't run all the way down, but the central section is as long as the sidebar?

Thanks in advance.

Tuesday Monday Afternoon Fun

I guess Al Gore's recent Nobel win sparked off a minor bit of furor in the medical blog-o-sphere (not to mention elsewhere) as shown by Scalpel and Shadowfax, I thought we all needed a little bit of lighthearted insanity. Zoobomb style. These guys are nuts. What better way to forget about the depressing issues of global warming, ER overcrowding and health care reform than flying down US 26 into downtown Portland on a mini-bike set to the music of AC/DC? Or having a blast barreling down Maryhill on longboards and mini-bikes? Enjoy.

The Hellway

Maryhill Jam

For what it's worth, I believe in global warming and that we should do something, even if it seems futile. I haven't driven to work more than twice in over 8 months, relying on bike and public transit. But that's me.

Update: Yes, I'm an idiot. For some reason I thought it was Tuesday, only to be corrected by my neighbor that it was Monday. The headline is now corrected...

First Night Back Blues

Recently I had an 8 day stretch of time off. Yes folks, 8 days in a row. And staffing never called. Not even once. The first time in three months where I actually wanted to work extra and had said, "If they call I'll go in" and they don't call. I found out later that census had been low, nurses were being floated and even sent home early. Talk about poor timing to try to get overtime. Guess it was a good stretch to have off though.

But I paid for that time off the first night. In blood.

Not really, just a lot of miles and a ton of sweat.

I started with 4 patients and I knew I was going to be busy. Intractable nausea and vomiting, a small bowel obstruction on TPN, demented little old lady post-kyphoplasty who had been taking swings at the previous night shift and in the morning, who had a hypertensive episode post-intervention and was still goofy from anesthesia and the winner of the night: post-stent to the RCA with the arterial sheath still in place, Integrilin running and ACT still sky-high. It was going to be an interesting night. Oh yeah, did I forget to mention the load of empty beds and me not capped?

I had it all planned out. First, see all my patients. Second, pass meds. Third get everyone settled in. Fourth, pull the sheath. Yeah, like things ever go to plan on my floor. Intractable nausea wakes up, gets Zofran, and some IV Metoprolol for her elevated BP. Demented LOL, wakes up and starts asking where she is, why she's here and who she is. Get her relatively re-oriented. Small bowel guy is doing just fine. Hang new TPN, walk him and get him settled. Finally, at about 2200 go back to see stent guy. Have everything I need in the room. Ready to pull the sheath. Stick him for blood for the ACT. And miss. My sheath buddy S. gets him. Except the machine rejects the sample. Try again. No joy this time, ACT is in the 180's, order is to pull after ACT<160. Tell stent guy to chill for awhile longer.

As I walk back to the nurse's station, charge tells me I'm getting an admit and report is on the phone. Remember those empty beds? Yep, got to fill them somehow. Take report. Go back to stent guy and check a set of vitals and he tells me he's having pain. On the left side of his chest right by his armpit. I ask him if it's the same as it was before he came with chest pain, hoping he's going to tell me it's not. Nope, not that lucky. He tells me it is exactly the same. Shit.

Run down the hall, grab the EKG machine with a quick stop at the Pyxis for nitro. Grab a 12-Lead, throw some oxygen on him and give him a nitro. While I wait for the nitro to work, compare the new 12-lead against the previous one and breathe a small sigh of relief as I see no new changes. Double the relief as he tells me the nitro worked and he's pain free. About that time, my pager goes off. Intractable nausea is puking again. Head over and she tells me the Zofran didn't do much. And that's all she has. I page the house doc for phenergan, send the order to pharmacy and wait. Phenergan comes up and I give it. Look at the clock and it's nearly midnight. Time for rounds and midnight meds. Pager goes off: phone call. It's the ED who tells me that my admit is hurting, nauseous, on the way up and I'll want to medicate her when she gets to the floor. I can barely get a "WTF?" out as she hangs up on me. Great, my favorite way to admit someone: in pain and nauseated with nothing to give.

I'm in the middle of pushing Metoprolol on SBO guy and my pager goes off, again. Oh, the admit is here. Now I'm starting to get pissed. Nothing is going the way I thought it would. The night I tried so hard to keep organuzed is seeming to be coming apart at the seams. I've been up and down the hall enough times to wear a track in the rug and except when getting report from the ER I haven't stopped moving all night. Have I charted yet? Not a chance. Heck, I don't even know if I signed off on all my meds. But now is when my co-workers stepped up. They got the admit settled, hooked up to tele and orders started. They even sent the pain meds and anti-emetic orders off. Did I mention I love the people I work with?

I go in and grab an assessment and vitals. Admitted for chest pain, but now it's more like a shoulder pain, cardiac enzymes and EKG were both negative and she's relatively comfortable, but the pain is coming back. Out to check on the meds. Not in Pyxis yet. Try again. No luck. Go finish up seeing the rest of my folks. Look again. Nothing. Go in to stent guy to draw blood, the ACT machine tells me it is time to QC, which takes 10 minutes. Go back out and the meds are still not up. I'm pissed. I'm pissed at the ED who didn't medicate before they sent her. I'm pissed at stent guy's ACT and the order from the docs to pull at less than 160, when protocol is normally 180. I'm pissed that it takes pharmacy an eternity to get anything in. I'm pissed that the guy who arrived after my admit, already has meds in, even though the orders for my admit were sent first. So I get on the horn. I politely and gently persuade (without sounding like a sailor) the pharmacist to at least put in the oxycodone and phenergan. And then finally, as if by miracle, the meds are available. I medicate, get a history, orient my admit to the floor and what's going to happen tonight and head back to stent guy's room.

The ACT machine is ready. I'm ready. He's ready to have the sheath out of his leg. I poke him and get a good stick on the first shot. ACT comes up...and it's still >180. Shit. "Oh yeah, " he says, "I'm having some terrible heartburn too and was a little nauseous." Great. Look at the MAR, not a single thing for heartburn. Look to see who's on call for cards tonight: Dr. Complex. A quick word about him. He's a brilliantly gifted cardiologist,who is both incredibly young and smart, but whose bedside manner is, how you say, lacking? Once a day nurse remarked to me that he seems so uptight they wondered if he even poops. He's not exactly my favorite person to talk to in the middle of the night. But I start going through stent guy's chart and notice that he's had a sheath in for well over 18 hours, closer to 20 it appears. It needs to come out. So I call the answering service to have Dr. Complex paged. He calls me back and is actually polite and understanding. I give him the run down, mentioning the chest pain, the heartburn and the fact the sheath has been in for at least 18 hours and that the ACT has actually gone up since my shift started. "Is it OK to pull it now?" I ask, and sure enough it's coming out. He also gives me orders for something for heartburn which are sent to pharmacy. Somehow these come up quick. Give stent guy maalox and have him pee. Grab my buddy S. to help me out with the pull and get ready to rock.

Except this will be the first sheath I've pulled. Being the good little nurse I am, I had looked at the policy earlier in the night, and went over it with S. to make sure I didn't seem like an idiot in front of the patient. Things are in place and we're ready to go. We pull the dressing off from over the sheath and stent guy goes green, then like a scene from The Exorcist, starts vomiting. In large amounts. S. has the sheath in his hand, I'm holding a bucket for stent guy, praying S. can keep the sheath from coming out. Stent guy calms down and stops puking then tells us, "I feel better now." Murphy was working overtime this night. He's OK, we're OK, time to get this sheath out. Clamp on the Fem-o-Stop, I pull the sheath as S. pumps up the Fem-o-Stop. We barely get a little ooze. We spend the next hour checking vitals, pulses and the site until we take the Fem-o-Stop off, slap on a D-Stat and call it good. Knowing I still have to check him frequently, I pulled one of the computers down the end the hall and start charting.

By the time 0700 rolls around I think I'm caught up. I don't feel like I'm caught up. I don't even know where the last 12 hours have gone, but SBO guy is chillin', having had a couple of small bowel movements, intractable nausea is up, awake, taking clears and her BP is stabilized, my LOL is fast asleep having remembered who she was, but not where or when, but that's her normal, chest pain admit is just dandy and stent guy is chillin' too, the D-Stat looks great, no bruising, great pulses and no more nausea, heartburn or chest pain. I got home and was asleep 30 seconds after my head hit the pillow. It was one helluva' first night back.

Inappropriate Comment of the Night

I had finished getting report from the ER on the 30-something year old male who had experienced and episode of chest pain while "getting ready" (his words, not mine) with his wife - guess he self-edited due to the fact his young son was present. He later told me he was "getting some hot lovin' with the missus." After I calmed down from laughing, not because it was terribly funny, but because I could only imagine the embarrassment of the situation, especially in the size of the place they had come in by EMS from. Word travels quick in small towns. Let me put it this way: he was of the size that you didn't even want to think or associate with the phrase "hot-lovin'." Not something I wanted to end my shift with. I wasn't hungry when I got home that morning either.

What You Don't Want to See

If you listen closely you can hear several things...

You hear the charge nurse watching the monitor at the tele station go, "Oh shit!" Jump up, grab the code cart and go hauling ass down the hall. Then the nurse at the station right next to him calling the operator and the overhead announcing "Code 99 to XXX." Next you hear the page go live and pagers going off and nurses running down the hall with the COde Team hot on their heels.

He was down on the floor, half in, half out of the bathroom, all 300+lbs. of him. No time to move so they worked him on the floor, half in, half out of the bathroom. One nurse was standing on the toilet with their butt in the face of the one in the shower. The floor was covered in the miasma of body fluids and blood as the guy came to a little and started tearing out IVs. They shocked him once and got a rhythm back and like a bat out of hell, off to the unit. If memory serves, guy came back up to our floor about a week later, in pretty good shape all things considered.

Looking at the strip several things strike me. One is that this the last time I ever want to see a R-on-T phenomenon live and in person. Second, dude was damn lucky he was in the hospital, on a monitored unit with ACLS-certified nurses caring for him and a Code Team 30 seconds away. If he had been out in the regular world, things might not have turned up so rosy. I guess this could have been a case of Sudden Cardiac Death, but he was lucky. Third is that how quickly life can turn on you. One moment you're getting up to take a leak in the middle of the night and the next you're on the floor after having died for a couple of seconds. Kind of brings things into perspective. Finally, that tele tech who the charge nurse was covering for while they were away at the bathroom? Yeah, they don't get a bathroom break ever again. This was not the first time. No, this was the third or fourth time that they stepped away and something unfortunate goes down. It's just bad luck.

I wish I had saved my other favorite strip from a while ago. It was sinus with an 7 second pause. All you saw were these little P-waves, but you could call it asystole. Like above, they were dead, if only for about 7 seconds (isn't that the length of a champion bull ride?).


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