LIFE, DEATH AND RENEWAL

A sense of foreboding gripped me as I entered the department. The aides were pushing a morgue stretcher away, leaving sharp intakes of breath and a muffled cry. Three nurses huddled around the triage desk, one nurse was visibly upset.

Outside the trauma room stood two burly policemen. The aftermath of a trauma resuscitation greeted me: the blood-splattered floor was strewn with discarded clothes, a used stylet, wadded gauze, and the blue overwraps from the instrument trays.

The night nurse looked shell-shocked. On Bed A, an unconscious male patient lay in a tangle of wires and tubes. The ventilator hummed and the monitors bleeped. Endotracheal tube to the ventilator, sinus rhythm on the monitor, an arterial line, two large-bore IV lines, a urinary catheter, right chest tube, right leg splint, dried blood on bandaged head, and his left hand cuffed to the side rails.

"Here's our 20 year-old trauma patient... this..." the night nurse bit her lip to stifle an expletive. "This person just murdered his girlfriend, her two children and her grandma. Shot them point-blank. He jumped four stories off the roof after he was chased by the police. All this because she tried to leave him after a night of beatings. That was the youngest child we just sent to the morgue. " Her voice broke and we both shuddered.

We stood at the bedside and shared each other's anger. The thought of the carnage this man left behind made me recoil in disgust. I felt a need to cry; bile rose up in my throat. Even in repose, this man's face looked so evil, almost satanic. Despite all the repulsion I felt, I had no choice; I had to take care of this patient. My training and my ethical responsibility will ensure that I give this patient the best of care, no matter what.

The night nurse struggled to finish the report. She was rambling, obviously wanting to simply put the ugliness behind her. I could only pat her back. "He's pending the CAT scan results. His pupils are fixed and dilated; he's unresponsive to any stimuli, no corneal reflexes, and he's posturing." This patient is as good as dead, I thought. The machines keep him alive.

As if on cue, the physician strode over. "He's got a huge subarachnoid bleed. No surgery for him. We're starting brain death protocol on him... and surprise! The cops just found his organ donor card."

Somehow, my anger simmered away. I clutched at one straw of sanity... in one rational moment, this man has willed his organs so that in his death, others could live. The organ donor card tells me that at one point in his life, this man cared enough. A little too late. Why couldn't he be as generous in life?

http://jo-cerrudo.blogspot.com/2010/08/ed-vignettes.html

Patient Privacy and technology

The advent of technology has a lot of advantages. With Yahoo Messenger, Skype and other internet chat/ conferencing services, we can now talk to relatives and friends around the world at no cost at all, or very minimal if any (that's if you have to go to the internet shop and pay per hour). It allows us to rant or praise through blogs, reconnect with friends and make new ones through networking sites, and practice our writing, photo editing, singing, dancing instrument playing talents. Mobile phones are becoming cheaper and more high tech, you can now have a mobile phone, a camera, a videocam, an organizer and an mp3 player all rolled into one teeny tiny phone (and that's just the basics). Technology allows for better documentation of our daily affairs, reunions, vacations, projects, etc. Unfortunately, people have gotten overboard with these new found powers. They air their dirty laundry for everyone to see, mess with videos and pictures to destroy people. Some are premeditated acts, and some just fell victim to ignorance. Sad but true, even nurses have had issues with misuse of technology.

The first sensationalized case in the Philippines involving nurses was the canister videotape scandal where members of the medical team deliberately videotaped (using a cellphone) a procedure on patient who came to the ER with a very humiliating situation. That video found its way to the world wide web. It was very malicious and there's no way it could be argued that it was (the videotaping and the posting) an honest mistake. They thought it was funny, and even funnier if the patient suddenly finds his face plastered on the internet. These were people, who took an oath, to respect the dignity of any patient, regardless of color, race, political, religious or personal beliefs, etc. Shame!

Then this year, the technology bust came through again, this time in the form of the right-of-passage summer ritual among boys - circumcision. It's nothing new, every summer, there's medical missions offering free circumcisions to young boys. It's tradition. What was new was this year, pictures from these activities flooded the internet. Worse, it showed young boys, faces, penises, and all. No effort was done to protect their privacy. Worst of all, members of the medical team were seen smiling and posing over patient's agonized faces, or their private parts being cut (and that oh-so-annoying finger sign!) I doubt one will argue the "free" gave them the right to do whatever they please. It wasn't that at all. It was ignorance, and maybe complacency. After all, it was a good deed, a medical mission. Surely, anyone would be excited to share in someone's being hero for the day....right? Pictures started being shared and perused by friends, friends' friends, and so on and so forth. Pictures were re-tweeted, side shows became available on youtube. And then someone cried FOUL!

All of a sudden, Filipino nurses and doctors are being called pedophiles, exhibitionists etc. We've been branded! There's even a facebook page about it. You should see what's being said about us over there. It's unfair to be branded and generalized, it's true. But what's even unfair, is that the patients' rights to privacy and confidentiality were again violated, our oath to protect was disregarded. Seems to me like that oath isn't worth squat.

We can blame technology but I think that technology has helped us (in a twisted sense) realize that in every action that we do, we always need to look at it 360 degrees. Specially if it involves patient care. The patient always come first. Boohoo, You can't post pictures of the excitement, or need to take time blurring patients' faces. But remember, you took an oath. Better serve up.

what if??

As a nurse, it's all part of our job to render health teachings to our clients. What to do, what to eat and drink. While doctors were the one whose explaining to them their medical status or medical condition. These were the routines were used to do inside the hospital.


But what if one day, you are the one whose hospitalized? You are the one whose lying on the hospital bed. You'll be the patient taken good care by others. Are you ready to listen? Are you ready to accept the findings? Are yo ready to face death?



Been asking this question inside my mind. Working inside a hospital, death is inevitable.





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dhee, r.n.

More Than Words

Hello dear nurses,

I got a call recently from a client who was desperately seeking support for a nurse accused of misconduct and facing losing her right to practice as a nurse in Ireland.

When first hearing about the case, I asked a lot of questions and it seemed that communication difficulties were among the issues that patients had complained of about this nurse.

When I sat down to have a chat with this nurse to see how I could help her, it turned out that she was highly educated and communicated quite well.

One thing stood out about her communication and that was her pitch (how high and low her voice modulated). After reading a little about her mother tongue, it turned out that pitch was used quite differently in her mother tongue than in English. In English, people often raise to a high pitch when annoyed or nervous or anxious but in Hindi, this nurse's native tongue, pitch is used to emphasise content that is important.

It seemed that this nurse was simply transferring a habit from her mother tongue, without realising the effect on her patient.

The episode clearly highlights that communication is so much more than the words we use; it's all about how we use them. Knowing a language is more than having an extensive vocabulary; it's about how we use that vocabulary. The use of pitch (high/low voice range) in English is very different to other langauges and good to know that a raised pitch signals some kind of distress or anxiousness, something that patients are bound to react to as it signals something is not quite right with the speaker.

Have you had miscommunications that were due to something like this nurse's miscommunication - more than words?

Until next time,
Marie

My Colostomy Story

A repost from my blog.

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Today, I had to deal with the dilemma of me being an experienced neurosurgery nurse, working in a general surgery unit. I worked in an ER and neurosurgery environment for the last seven years, and I knew that I would be faced to deal with some unfamiliar cases in a new work place.

I had a patient with a colostomy. Well, it may sound so simple for some general surgery nurses out there, but it was a big deal for me. It’s not that it was my first time, because I have had several patients with a colostomy. But it was my first time in several years to actually perform colostomy care – to actually touch and clean the stoma.

I was busy with another patient when I heard somebody screaming. When I looked out of my patient’s room, I saw one of my co-nurses coming out from one of my patient’s room. She asked me if the patient in room x is my patient, so I told him yes and asked her what’s wrong. She said the patient was complaining because he was yelling for an hour already and nobody is coming for him.

Since I was finished with my current patient, I decided to check the complaining patient out. I went to his room and I was welcomed with some more yelling. I asked him if he was pressing the bell since that is the proper way of calling a nurse. He said he did but it seemed the bell was not working.

I investigated further, and found out that the bell cord was not attached to the plug. So that was the reason nobody was coming to him. I was successful in trying to pacify him. I asked him what he needed and found out that his colostomy leaked up to his back. He said he was trying to open his colostomy because he felt it was full of air. When he opened it, he got surprised with the contents and everything leaked out and went to his clothes and sheets.

My patient had a colorectal cancer and the surgeons tried to remove the cancerous part of his large intestines. A new opening was made on the left side of his abdomen where his stool can come out, and will be drained to a pouch called colostomy bag.

I checked what I needed to clean him, and after that I told him I need to get some things in the stockroom. When I got into the stockroom, I took some fresh linens, pads, cleaning wipes and saline. To my horror, I found that there were different sizes of colostomy bag. How would I know which one is for my patient? I decided to just bring one from each of the different sizes. I thought it would be safe since I do not have to come back if one size fails.

When I went back to my patient’s room, I checked his colostomy so I could choose which size of bag I would need. To my surprise, none among those I brought were the same as my patient’s. I needed the biggest size which seemed not available because I did not find that size before. I knew I took one sample from each of the sizes I saw.

I went back to the stockroom and searched for the largest size. I did not find any, so I asked one of my seniors. He helped me search until he finally said it was probably out of stock.

I decided to go to another ward and asked for that size. I knew that every minute counts for my patient who was irritable initially. I found the size from another surgical unit and hurriedly went back to my patient.

When I got into my patient’s room, I was greeted by a frown. I explained to him why it took me a bit long to come back, that I needed to get his size from another unit. He seemed dissatisfied with my explanations, so I just tried my best to talk to him nicely.

I detached the old pouch from where it was connected. I placed it in the bathroom since I wanted to save the wire that closes the pouch at the end. I cleansed his stoma with normal saline. After cleaning, I tried to attach the new pouch to the connector. It seemed I could not connect it. It was either I was doing it the wrong way, or I just do not know what I was doing.

While I was trying to attach it, I tried to converse to him to try divert his attention from what I was doing. I explained to him some facts about colostomy, and how to take care of it. I was posing to be a pro with what I was doing, when deep inside, I knew I could not connect the bag. It was hurting him when I pressed harder on the pouch lid.

I then decided to ask help from a co-nurse. God probably heard my heart beating fast, and gave me a colleague just passing by my patient’s door! I asked her to help me attach the colostomy bag. She told me how to do it and watched me do it. It was the same technique as what I was doing before. But she also felt it was difficult doing it that way so she suggested for me to just remove the part that was attached to the skin, and apply a new one. The adhesive part that was touching the skin and the bag should already be connected before sticking it to the skin.

I actually thought of that, but I knew it was the harder way of changing the bag. But now, it seemed there was no other way but to do it that way.

I was successful in applying a new bag on him. I went back to the bathroom and took the wire from the old bag. It was heavily stained with stool so I just tried to clean it. I closed his colostomy bag using that wire.

I wiped him a bit, and brought him to the bathroom after that. I changed his gown and placed new linens on his bed. His mood has changed, and was apologetic about his attitude a while ago. I told him it was pretty understandable for him to get mad in his situation. I left him clean and satisfied with what I have done for him.

In the evening, before I left the unit, I checked him out in his room. He was with his family, and I was introduced to them. I told him that my shift is over and that I was leaving. He asked who’s replacing me, but I was not sure who’s taking care of him next. I saw in his face that he still wanted me to stay for him.

Before I left, he said smilingly “See you on Sunday!”.

(picture credit: butler.org)

A day in a life of an EMT: Drink while driving

Several weeks from now, it's going to be October. We all know what that means; it's going to be beer, beer, and more beer because of Oktoberfest. And as you've noticed, I'm overlooking September since I'm still assigned in Rockwell post for the whole month, which FYI-- is the most benign post you'll ever get assigned in. We hardly have multiple runs in a shift there. Sometimes we get lucky but most of the time we run once, and the rest is all eat and sleep.

It will be my first October in Lifeline so I'm not familiar with the statistics of trauma but I'm guessing we'll be having Lifeline members driving piss-drunk that month. I could be wrong though; investing in healthcare is something a smart person would do. A smart person wouldn't do stupid things like gulping vino and then go behind the wheel.. but hey, we can't put alcoholics and juvenile delinquents out of the picture right? Haha. Let's face it: idiot drivers will give me much of the practice I need in intubation. I swear if I encounter an RTA with GCS 8, the moment the cot locks at the back of the ambulance I'll be over his head, prying his jaw open with a Macintosh. Medical practice. Nursing practice. Eh. There's a reason why they attached the word "practice". Of course I know what I'm doing; indications, advantages, disadvantages, complications.. I took ACLS. The success rate, however is an entirely different thing. I know what I'm doing, I'm just not that good at it yet. Burned!

So when October comes, think twice about driving drunk. Sure we' ll save your life; dial 16-911 and we'll be happy to extricate you from your Prius (with spinal immobilization of course). But the time you don't respond to sternal rubs and then your oxygen saturation takes a nosedive below 90% despite a well secured BVM before we reach the nearest ED, I assure you I'll be the first one to shove a tube down your throat. Drive safe people.

A Push to Future Nurses

"I did my best and I know I have my chances." - an excerpt from a now RN friend.

This is one statement that stuck in my head years after the night our NLE result was released. I was fortunate to have passed the exam but was also heartbroken trying to comfort good friends who did not make it. It never occurred to me that the minute I become a boardpasser I am to apply all the nursing therapeutic communications I have learned in and out of the classroom. During this time it was hard to be full-throttle celebratory that I could only settle with being thankful.

The NLE, like any other board examinations, can be a life-altering event. Making it to the roster gives license to practice one's chosen profession. But while others take it as one huge step to reaching their dreams, to some it becomes a make or break deal. I have seen test-takers who were either disheartened or digressed by ill luck in this exam. Perhaps because we program ourselves to pass and never do we make any contingency plans that we put ourselves into instant defenselessness. Not making it the first time then becomes a more onerous test - a test to one's character. There are those who start to question their abilites, others turn either cynical or sour, and there are those who hastily decides to call it quits without attempt for a second try.

Bereavement is normal. We are humans afterall. But redemption will have to be a matter of choice. To those people who remain averse about retaking the exam will never know the difference; while those who prefer to rise to the occasion will have their chances of becoming certified one day. In this case, fortune may clearly have to favor the brave.

With the recent release of the new batch of registered nurses, I can't help but look back at that night when I had to share strength to colleagues who needed them. Years passed and I am proud to say that these friends of mine are not only licensed, but now fair in the industry, simply because they did not give up. What our future nurses should not fail to see is that NLE is a rite of passage; and it serves another purpose of bringing out the best or the worst in its test-takers, either of which for their own choosing. Life is larger post oath-taking to just miss out on it.

I often say that it's not about who's the smartest or who's the most studious in class who succeeds in this kind of endeavor. It has got to be the most determined that brings home the greatest reward. Because in a parallel universe where the smartest, the studious, and the determined all fail, the latter already has the determination, the spirit that will deliver.

Call a Code Blue!- A brief education on a medical emergency

So who doesn’t love a good medical show? Nowadays the shows that are medical related are a dime a dozen. From House, to Grey’s Anatomy, to the never forgotten ER, these shows give us a peak in the lives of health professionals. What I want to talk about though is the infamous code blue. You guys know that moment in the show where you see the health staff yelling “code blue, code blue”. Then you see the patient on their bed pale, unresponsive, and they look like they literally have no life left in them.

In this article I will explain the basics of what is going on in the person especially their heart and what the medical staff is basically trying to do. This will be nothing to in depth just a basic education, because to be honest what is exciting to watch in TV is actually very scary experience in person especially if it is your own family member.

The heart which I like to call the “Real Muscle” of the body is responsible for ejecting blood to your major vital organs of your body. Without your heart outputting a sufficient amount of oxygenated blood, your organs suffer and basically don’t get their needed oxygen. I know all you guys have held your breath before and what you are basically doing? You are depriving the body of oxygen which your body needs and ultimately building up carbon dioxide which accumulates.

So which leads me to my next point, your heart rhythm is basically an electrical conductive system. Your heart has pacemakers to help set the rhythm and the rate at which it pumps. The main pacemaker of the heart is your SA node, but just in case that one fails there are backup mechanisms. With that said those backup mechanisms aren’t as efficient as the SA node. Your heart basically is full of fail safe pacemakers just in case anything goes wrong, but they may not pump at a proper rate or put your heart in a proper rhythm. When your heart is pumping in its proper rhythm it is called Normal Sinus Rhythm which pretty means Life is GOOD! You are getting proper cardiac output and your heart isn’t working too little or too hard, it is going just right.

Two of the main deadly rhythms that are mostly seen in a code blue situation are Ventricular Fibrillation and Ventricular Tachycardia that is pulseless. These two heart rhythms are so erratic and so inefficient that your basically getting no cardiac output. The ventricles of the heart which are parts of the heart have the ability to be pacemakers but are horrible in doing so. So what you get is a patient with an abnormal heart rhythm with basically no cardiac output. Especially in Ventricular Fibrillation the heart is basically just quivering with no real actual efficient pump to eject the blood.

In the hospital when we notice this we call a “code blue”. Our basic goal here to either shock the heart back to a normal rhythm to help re-sustain some decent cardiac output. The quicker we are to react as health care professionals of course the better the outcome. Every second we don’t do something we are depriving the entire body of oxygenated blood. We use the defibrillator which will basically deliver an unsynchroized shock or electrical energy. What happens when the shock is delivered it trying to depolarize which basically means we are trying to reset the rhythm of the heart, in doing so we would hope the SA node would kick back in and reset the heart to a normal sinus rhythm.

I can go further in depth on this article but it would take me another page . I just wanted to give a basic brief summary. Once the heart rhythm is back there is many other things that can happen or must be done. For instance, trying to sustain a normal blood pressure or trying to raise the heart rate. I will save that for another day. In the meantime when your out in a public place and see the little box with the letters AED. That stands for Automated External Defibrilator and is used just in case someone needs it in a public setting.

Jed Jularbal, BSN, RN
The Methodist Hospital- Houston Texas

Email: jrjularb@gmail.com