...It's been awhile

I know, I know. It's been ages. This is just that time of year where the whole hospital is on diversion and staffing is depleted because, SURPRISE, everyone gets sick from being over worked, and oh yeah, working with sick people. Moral is borderline through this time of year to say the least, so why not work all the holidays too!

Bright side is that I got engaged! I finally caught a boy! Time to break out the ball and chain I've been hiding in my closet and secure it firmly to his ankle. Hah. He prob doesn't quite find this as humorous as I do. I now have a pinterest problem that is borderline unhealthy, but sooo much fun until I get the calculator out and adding up costs of a wedding.

Since the last post was the most depressing thing I've ever dealt with at the hospital I will do all of us a favor and write some funny/dumb things I've encountered lately.

Here's a good one from today. Back-story: I was working in a post-op CT surgery icu (open hearts etc) admitting patients/running around doing a million things at once. We have a set protocol for vent settings/weaning/extubating these patients (so variations on vent settings have to be ordered). I was admitting a straightforward case this afternoon w/ the RN and a bright and shining NP student was bagging while I got the vent ready...

Baby NP: Did you get my settings?
Me: Yeah (they were written on report sheet).
Baby NP: Well, I have the peep at 8.
Me: Okay. Because they are bleeding?
Baby NP: No, I don't think so. Wait. Let me check. Just go ahead and change it.
Me: Did you have oxygenation issues in the OR?
Baby NP: No. Are you going to change the peep now? Well, let me just do it for you.
Me: Nooooope. (at this point I'm annoyed and not entirely sure she knows what peep really does, and I go stand in front of the vent and write down some numbers).
Anesthesia fellow: Well, Baby NP, what's your reasoning behind higher peep right now? (we are all now trying to figure out rational).
Baby NP: I am just following evidence based medicine.
Me: Which paper are you referencing?
Baby NP: ....uuuuh...
Attending: Okay, Baby NP, why don't you go make copies of the report sheet for everyone (a fools errand bc 1. we all have sheets anyway and 2. good luck finding our copy machine password).

As soon as they walk out of the room in search of the impossible copier we bust out in uncontrollable laughter. Attending for the score!Lesson: Don't be a cocky student. And DEFINITELY don't be a cocky student that has no idea what they are talking about. The rest of the day all the doctors asked me to turn up the peep on non-intubated patients. We laughed, but in reality the scary thing is that at some point that NP will be taking care of really sick people. Hopefully the Baby NP will find some humility soon...

Fibromyalgia. I added that one onto the list of patients that I don't trust (along side of patients with multiple multiple allergies to things like gluten, Ibprofen, tylenol, ultram, cilantro, and all kinds of tape). I think it's the perfect diagnosis for hypochondriacs. Juuuust an observation.

Anywho. Bedtime for this lady. More fun awaits me in the morning.

Listen

I'm kind of at a blank on how to begin writing this post today. It's hump day, and I've spent most of it on the couch reading some horribly offensive young adult novel about categorizing citizens blah blah blah. I guess it made for some interesting dreams last night with crazy people chasing me with guns and sappy love stories that included someone referring to me as "Lucky Charms." I guess it's a play on my Irish name of origin, and as he so boldly put it in the dream, "...Lucky Charms, because you're magically delicious." Yeah, even my subconscious is weird.

I started to write a post a few weeks ago about this really bad night at work. I walked out of that code that night with a red hot face that was bursting with anger, and tears that were so heavy that they just collected in my eyelashes before dropping down my cheek. Completely lost my shit. In response to try and deal with it all, I started writing a new blog entree to relieve the festering anger and allow me to sleep, but all that came out on paper was a bunch of childish comments and sarcasm to cover up how much that night hurt.

I'm glad I didn't post that rant, because I just read it over again and I can honestly say that I sounded like a brat. I was writing to vent (yes pun intended). Now I'm a little more rational but I still need to write about it. With that in mind, the specific details of the code are really miscellaneous. However I will say that I tried to tell the MD three times over that this patient needed x, y, z and to page ENT, oh about 3 hrs ago. The MD did not listen to my suggestions, and the result was a code blue nightmare that left me raging with guilt.

Guilt because I had failed to help keep this patient from harm. Anger because my voice was silenced without consideration. It was only in the desperate moments at the end of everything that they finally listened to me, but at that point it was really too late. All I could do that night was cry behind the ABG lab door for a few minutes, compose myself and then get on with work.

After retrospection and some counseling from my sage adviser I calmed down from the moment. It took a few days for the emotions to subside completely. I don't break down often at work, so it kind of shocked me when I couldn't let this one go. I get irritated at coworkers all the time, and use those moments to remind me that I am not a prisoner of my job; it motivates me to get my ass in gear and go back to school. But this code was different. I couldn't use a patient's death to spark my inspiration to take Chemistry in the fall. It felt like a cheap way to deal with it.

I don't want to fall into the trap of going to PA school just so I can be the decider and write all of the orders. It has to be so much more than that. I know I make mistakes. I know I am not always right. Disagreeing happens. What I find respectful in a practitioner is one that will listen to my argument, say no, but then give a justifiable answer for the decision as to why they don't agree.

Sometimes it is hard as a RT to remember that we are really there to follow MDs orders. That no matter how much value we have in critical care, all of that, is easily forgotten when up against a practitioner's inexperience/ego/stubbornness. It hurts our esteem as qualified members of critical care when our suggestion is met with a blank stare, and shot down without consideration. Every time I move up to the Esteem rung on the Maslow's hierarchy of needs pyramid, an event like this one threatens to bump me off again. I really think that is why so many of us burn out. Most of the time it is a thankless job, and I know for me it is very hard to gain that self-esteem back when I am not respected in my profession. Over, and over and over again.

I wanted to go talk to that MD after the code so badly, and have the "I told you so" moment. I felt like it would make me feel better or give me a taste of validation. I also thought about writing them up for a litany of reasons in the name of patient safety. But I didn't. I'd like to say it was because I took the high road, but really it was just to avoid confrontation because I was still so upset.

I suppose I'm still hanging on to it a little, still trying to process that night. I guess I'm still human. Thanks for listening.

sick

Strange to think of it this way, but...

Please learn to work in a hospital while you are sick. Just go ahead and accept that. I'm not joking. I have learned over the last few years of work that calling in sick/out for family/life issues will cost you dearly. I'm not saying this from a bitter perspective; rather one to help new grads/new hires realize where they sit in the caste system of your department. The punishment will come in several different manifestations, but the end result will be the same; emotionally draining. Because, honestly, we don't get enough of that as is. I've put together a list of things to help you as a newbie, that I've had to learn the hard way:

1. Learn your attendance policy backward, forward, and every space in between. Seriously, look it up, print it out, and know what is expected of you.

2. Get the flu shot. Period. Don't even argue on it.

3. Find someone at work to be your go-to for switching shifts. I've saved myself a few sick days just merely asking a co-worker to switch and give me an extra day to rest when I'm sick.

4. IF you are throwing up, running a raging temp, coughing up phlegm buckets, or have a hemorrhagic viral infection ( ie, Ebola), do not go to work, and do not let anyone make you feel bad for calling out. Remember that you are involved in direct patient contact, and any of your harmful germs could really push a very ill patient over the edge.

5. Stay on top of getting your licence renewed. CEU's creep up on you reaaaaally fast when they are due.

6. Get a reliable car, but make sure it's with in your means.

7. Zyrtec in the spring, airborne in the fall.

8. Yoga/meditation for your mental health. That's very important too.


Switching subjects, because I'm so great at that...

I'm actually enjoying my new shift. It's not a huge change (right now I work from 3-11pm, and 11am-11pm), but it really makes a big difference: 11am-7pm. I'm in love. I still get to sleep in, and also leave work at an earlier hour so I can work out/get groceries/socialize with normal people.

It can sometimes require a lot of flexibility. I spent the first four hours helping out coworkers cover lunch and/or recovering the CABG/heart patients that roll out of surgery and then I pick up an assignment at 3pm to cover the Q4 vent checks in an ICU until the night shift crew rolls in. Sometimes I find myself not really getting a break in all of the switches, but I generally am in a much better mood since it means I get to leave early.

This summer is going to bitter sweet when it comes to work. A few of my favorite co-workers are finishing up their masters degrees and will be out on the hunt for new jobs. I'm really happy for them with all of their new opportunities, but I am sad that I won't have my good friends to joke around with anymore. Like I said, bitter sweet.

Anywho. This pollen is raping my face yet again. Spring time is killing me right now.

One last little fun bit.... One of the attendings at work dropped this one-liner that had me in stitches. "How about you get the orders from your BRAIN".

Bored

Today is a bit rare. I actually have some time to write on this here ole blog thing. Well, maybe I've had time here and there, but between sleeping and complaining I kept putting it off.

Here's the current list of complaints: my back hurts, heavy ass work assignments, zero interest in budgeting my monies effectively, bills, no trips on the horizon, patients asking for stupid things, AOS (attending over-ordering syndrome), brand new impossible charting standards, cold weather, other people's weddings that bogart my time off, lack of desire to work out, days off that are spent running errands/cleaning, and just that circular grind that happens as soon as you get a big girl job.

I walked outside this past Sunday into sunlight in a t-shirt for the first time this year. I think that's probably the most cheerful I've been in a while. I'm pretty sure it's just burn out and being over-worked that's kept me down. I even tried a "stay-cation" to help re-set my mind, but all that ended up happening was far too much netflix watching and doing a whole lot of nothing. It was quite nice, but I also feel guilty because I had multiple adult-like responsibilities to get done and...nada.

I knew burn out would eventually happen in this profession. Sure, there's way more I could learn and work towards on improving patient care, but when I have a 12 hr shift that is completely packed with tasks, it is kind of hard to read about new research and refresh my knowledge on protocols. It really does depress me that I can't spend time with a really sick patient because I have twenty other miscellaneous  treatments on the floor to finish in a 2 hr window if I want to be compliant with med charting standards.

I never realized when I was getting into this profession that people are lazy. Keeping patients alive is so difficult, and what's even harder is knowing that what we do is futile most of the time. So all those stat orders are just taken with a grain of salt. What's worse are the cliques that form and just let the outsiders flounder when they need help.

I need to sleep. And do a little more pondering.

Pop Quiz

I've started to realize that I lose my filter in conversation as the day progresses. Chalk it up to being extraordinarily over worked, mental Olympics to get report ready, or that one last stat abg on the floor that winds up with critical results on every. single. line. So games are always fun, so here's a multiple choice pop quiz because I know a lot of you guys are students.

1. In a 12 bed MICU, what should be the maximum amount of vented patients ONE therapist should be assigned?
a. Four
b. Two, as well as other admits/breathing treatments and maybe a floor
c. Six
d. Ten, plus a floor with tons of frequent fliers with flu/wheezes.
e. N/A because your hospital has fantastic staffing (*envious*)

2. When you have an emergent intubation on a patient that has an unknown metabolic acidosis, would you put them on normal "nbrc" modes (rate of 10 or 12) of ventilation to begin with?
a. True
b. False
c. It doesn't matter because the NP has no clue what he/she's doing and he/she will not listen to what you have to say.

3. Who should ultimately be held accountable for a patient?
a. The attending
b. The admitting surgeon
c. The RN/RT
d. The resident
e. What does that word mean? aaaaah count ahhhh bility?

4. What is the fastest way to anger a mid-level (PA/NP)?
a. Ask how long they worked bedside before getting their licence
b. Tell them that the changes they want you to make are dumb
c. Go call the attending with questions instead of asking them what they would like to do
d. All of the above

just for fun one more

5. Why does PACU suck for me so much?
a. Finding supplies is absolutely impossible
b. Anesthesia trying to tell me to put a patient on 10cc's/kg because "that's what they need"
c. I have no clue what the patient had done in surgery or what the nurses name is
d. No therapist is actually assigned to that mess and I frequently have to deal with it
e. Being paged for a "wake up vent" in bay three because anesthesia wants to go home early



"Answers" per me.
1. b. I don't think one RT should have to round on more than four vents in an ICU. That takes in consideration getting the Q3 vent checks in as well as all the little abg/vbg/mvo2/mini bal/coding patients/new admits going crazy that pop up like they do. I once had an ICU that started with 3 vents, and then ended up with 9 at the end of my shift. Can we say tbh, fml. Oh, and a floor added on to all that nonsense. This is a staffing issue. There are 8 therapists on the shift, one supervisor, and 8 ICUs.  Let's not even get into the floors/ER that have to be tacked onto the assignments. I'd be interested to hear how other hospitals are staffed, so if you feel strongly about therapist to vented patient ratios, leave me a comment.

2  b. False. I'm a fan of lower tidal volumes and higher rates, so I set the rate high to blow off CO2 to compensate for a low bicarb. No one knew where the acidosis came from, but yet the NP wanted to start weaning the rate on a perfect gas before we even knew where the met acidosis came from. Why would you start weaning the minute volume before addressing WHAT KIND OF ACIDOSIS IT IS/FIXING THAT FIRST?! Once the acidosis is starting to be resolved, I'm perfectly fine with weaning rates, but not when the bicarb on the patient is SIX. Ok, rant is mostly over.

3. E. Very rarely will someone step up and be accountable for a mistake. The other day I saw a cardio-thoracic surgeon causing a huge scene in the ICU because a resident didn't order a mixed venous on his patient who was in heart failure. Well, mister CT surgeon, you can yell and scream all you want at us about accountability, but you were the one that did a mitral valve repair and coronary arterial bypass graft x2 open heart on pump on a ninety-something year old with multiple comorbidities.

4. d. all of the above. heh.

5. Every single bit. a b c d. But answer E really ruffles my feathers because these patients are on one of our vents for MAYBE one hour, and are charged about 3k because someone's feeling lazy. Sigh, oh the issues with healthcare.

Anyway. Quiz time is over for now. Just another way to skillfully organize my complaints over the last few weeks.

I think I've touched on this subject before, but I'm going to go here again anyway. I believe in hospice 100% for end of life care. I also believe that having a solid plan put together for a senior citizen would save a whole hell of a lot of money for the patients, hospitals and the government. But shhhh. No one likes to talk about death, and how most people face their last day on earth as torture with tubes in every orifice. The old and dying population account for 80% of healthcare costs, but yet family members still want everything done to their 92 year old grandma that is constantly aspirating her tube feeds and has basically no sedation because the PA wants to be "progressive" and not use continuous drips of seditives. Next stop for grandma is trach and peg land, and then get ready for some faaaantastic nursing home care that will include huge decubitus ulcers, and some kind of new antibiotic resistant super bug that's been going around in that facility. But the last stop is back to the hospital and into the ICU/ED where we will still try and keep her alive by shoving needles in her for central lines, a-lines, and doing cpr that will most undoubtedly crack a few of her frail ribs. All of that, or, grandma gets to be in her warm bed at home with fido curled up by her side, all of her loved ones next to her, and the hospice nurse dosing her up on morphine to help ease the pain and work of breathing from her heart slowly giving out.

I just don't think the general public is aware of this. I wish that weren't the case, I honestly do.

Spidey-sense

I was having an interesting conversation with a resident earlier (and actually, gasp, enjoyed it) about how to know when to intubate a patient that looks like poop, but has a relatively normal blood gas. It was interesting in the sense that he really was looking for my opinion/experience on the matter. We bounced ideas back and forth and came to a few major points to look over. 

1. What does the patient look like? Labored, sweaty, pale, jaundiced, only awake when aroused, old/young? 

2. Are they oriented to time/place (sans hypercapnia)? (ie could they anticipate vomiting and warn someone about it?) 

3. What disease process(es)/history is causing this? Someone with ESRD can usually be fixed with bridge bipap/dialysis, whereas a stage 4 met lung CA patient is terminally ill and will succumb to the disease eventually.

4. What are the other vital signs/labs? Basically, are they about to code b/c their BP is labile and HR is jumping from 120's to 180's with a few pvcs thrown in there? 

5. Does the patient/family want aggressive care? Code status and the patient's wishes should always be respected if they are of sound mind (medical power of attorney plays a role, too)

6. Spidey-sense? This one is just something I've acquired over time. Call it intuition, my experiences in the ED, ICU or pre-coding patients on the floor... I just can tell when a patient is coming up close to needing life support. 

Those are just some good starting points (no particular order) in making a call on those borderline patients. I feel like one of the most obvious green lights for intubation on airway protection is status epilepticus that won't respond to benzos/barbituates (also taking into account respiratory drive depression from those drugs as well). Flash pulmonary edema in extreme cases, epiglottis (this is an absolute), hemoptisis, unstable NSTEMI going to cath lab, drug overdose, and history of very difficult airway in resp distress are the other big ones that I would push for intubation. 

Personally, I tend to go with that if the patient is exhibiting at least 3 of the 6 points I brought up, I will voice my opinion. Now, most of the time I don't make that call, but at least I can put forth my two cents (whether it's taken seriously depends on the boss man in charge). I do find it hard to swallow some days when I can see an intubation coming from a mile away, but no one will listen to my plea because abcdefg reasons.

I know I have more to elaborate on this subject, but it's late and I have another long long shift coming forth tomorrow. 

I hope you are all enjoying the lovely fall weather :) 

feeling feelings

So. Lots to discuss, but not enough desire to bore you with all of it. Just enough to keep up with the changing tides.

Work is a constant evolution of face palms. 1. work load. 2. computer systems changing at the same time as 3. annual check offs that are convoluted and weird 4. the suits and their obvious  and completely horrific displays of favoritism 5. being sick, triggered from work load 6. breaking bad is over and I no longer have something to small-talk my manager about 7. i dont like the new set of residents because one of them ordered an abg & electrolytes on a dnr/dni patient just to check a k+ level that should have been tacked on in morning labs that THIS RESIDENT FORGOT TO ORDER. And wanted me to help them put in the a-line. At 10:30 at night. Noooooope.

Anyway. Perfect segue into reasoning behind going back to school...

Apparently... a university system hospital that is of a "public service" entity,such as the finest university system hospital I am currently employed (hopefully to stay thus), reaches the bracket of loan exemption. Listen up kids, this is important. So, if I make 170 qualifying payments to my stafford loans (about 10 yrs give or take with some wiggle room), I can qualify for student loan forgiveness. Breaking it down...

Let's just say I have less than 20K in loans now. If I keep paying, go back to school and finish up prereqs for PA school, keep paying on loans through the PA program (which would be optional), exit said program with a price tag of 140K, and meet the criteria for loan forgiveness upon graduation and re-hire from current hospital employed....

Deep breath. Sigh. Could it be? Education that doesn't completely rape your bank account for the rest of your life? This all seemed too good to be true. Maybe it will all change someday soon, but for now I would suggest peeking into the current gov loan forgiveness program. I've let student loans deter me from going back to school for 2+ years, and I'm no longer letting the fear of repayment keep me from achieving my goals.

So the decision has been made. I'll start chipping away at classes over the next few years with the over-all goal in mind. Deep breaths again. It all begins in January.

I have felt kind of nostalgic tonight. Whether it's just been from writing on this blog, getting out there and having my adventure fun times, or just relationships (friendships and relationships alike), that are keeping me on edge...slightly. I feel like I've let some good people slip through the cracks. I wish some of my exs had just been friends, and nothing more. I can see now that I should never have held such amazing characters up to my fine-tip comb of my inadequacies.

As far as the ever-stimulating game of dating is concerned, I met someone. A person that's pretty important, and sees the bigger picture. We shall see how it evolves.