A-fib…

In the simple telemetry readings I do, one characteristic that I look for when interpreting A-fib is irregularity, and either no P waves or inconsistent P waves. I interpreted this one as: A-fib with RVR (rapid ventricular response). The areas that are circled are components of the beat without P waves.

A-flutter…

This strip was the one that I previously mentioned that taught  me the importance of being observant, even in the midst of report. Our standard format is to read the tele strips with the top lead as II and the bottom lead as either V or MCL. Our hospital policy is that we are never to turn off alarms…so even when a patient is in A-fib, for instance, the alarms that ring “irregular heart rate” are perpetual and constant. So, the previous tele, to get around incessant alarming (because the patient was stable and asymptomatic) changed the lead reading to prevent alarming. The lead reading was put as a V lead for the top strip and II for the bottom strip. I was not informed of the change and didn’t notice it as I hadn’t settled in to my station and was in the midst of getting report. So, I saw what  was alarming: “V-tach.” When I ran the strip and looked at it and had the Doc and the Nurse review was my face red…the II lead made the rhythm an obvious A-flutter…(there is some wandering baseline and artifact, but the rhythm was definitely NOT V-Tach).

Telemetry Strips…

I recently learned an invaluable lesson…BE OBSERVANT! We usually watch our monitors with all leads on the II lead as the primary lead and wither V or MCL as our secondary, comparison lead. One of the techs changed the viewpoint on the telemonitors so that instead of II being the primary lead observed;  lead V was the primary focus. I didn’t notice this and a patient who was in A-flutter was presenting on the lead V viewpoint as V-Tach. It  alarmed me as I noticed the potentially dangerous rhythm without marching it out. On our monitors, when an alarm is on the observable lead that is primary will populate into a bigger screen…so lead V appeared to be V-Tach. When I printed the strip and showed it to my Nurse she said — “not true V-Tach…make sure to look at  the secondary lead strip…the patient is in A-flutter. You are seeing an abherrant conduction in the primary lead.” I felt like a total f**k up!. I generally DO look at the big picture and compare and contrast both the primary and secondary leads. In this case, I was just finishing with report and not really settled in (or apparently paying attention). SO….now I know to double check my lead setting before making an interpretation; AND, I will ALWAYS make sure that when I report I advise the oncoming shift of any monitor changes I’ve made. This was a great learning opportunity (and the strip will be posted in a day or two — trying to figure out my new scanner).

“Knowledge comes, but wisdom lingers” Lord Alfred Tennyson

This experience gives me both knowledge and a bit of wisdom. For that I am eternally grateful.

Blessings and Light.

Blitzed Again…

I worked Ick-U last night with THE NURSE. It was going smoothly because we had 3 patients, 2 vented and one DKA. I had 2 nurses…one who is willing to mentor; and then THE NURSE. I had all my work done by 9pm and still stayed very busy helping my Nurse’s with their patients.

THE NURSE has a problem with the fact that I have insatiable curiosity and ask a lot of questions. She often misconstrues my questions to promote my own learning and progression as me being insubordinate, rahter than me merely being motivated to learn as much as I can. Well, I am a Master at the basics, however, because we clash I always defer to THE NURSE. Last night I just couldn’t keep my mouth shut…we were bathing, turning, and positioning a woman who was intubated via an EndoTracheal Tube. She was on 90% O2 and only saturating in the low 90%. She had rhonci and rales in all four lobes. Well, THE NURSE (who has been a Nurse for 40+ years) was nearest to the vent. This position placed her nearest the tubes and the thingamajigs that hold the vent tubes at an appropriate angle from the machine to the patient. I told her she needed to give me slack and disconnect the tubing from the holders (she knows better than to leave the tubes attached…she’s been a Nurse for four decades)…well, she opted not to do as I suggested and take the tubes out of their holders; and, she opted NOT to give me slack…so, sure enough…the T-tube popped off, as did the connection between the ET tube that was in the patients mouth and the inline suction devices. Anyway, the patient started emitting thick yellow-brown mucous (or is it sputum when it is expired…I forget the proper language…but I am hoping you, the reader, is getting a visual)…she also started having spittle and air bubbles emerge from her nose; AND, she was gagging on more spit, phlegm, and mucous that was pooled inside her cheeks. She started to choke and gag, and I was almost certain she had aspirated.  Anyway, THE NURSE got mad at me for not holding the patient correctly! I had her turned using the soaker pad and using the recovery position as the patient was a heavy set woman. My hold was fine, THE NURSE just wanted me as her personal punching bag because she was in a hurry and didn’t follow common sense or prudent care with the tubes.

All ended up being well with the patient because THANK THE LORD our Respiratory Therapist was in the room with all of  this going on and quickly and efficiently suctioned the patient with both in-line suction and yaunker suctioning, flushed the in-line with saline to clear the sludge that was getting clogged in the line, suctioned a little more to clear the airway, and put both the T-tube and the ET tube back together. We were really lucky the RT was there helping us or we well could have extubated the patient (note to self…if I ever become “seasoned” still take time to listen to my support staff, they may be observing something I am missing that ensures the patients well being).

Well, THE NURSE being older and a little on the lazy side had another line mishap — the patients Miller-Frederick tube came out. The patient was in 2 point restraints per our vent protocol but was still agitated and restless. Perhaps when the patient turned her cheek on the pillow she rubbed her face hard enough into the pillow to pull it out? I am thinking this is the only plausible reason the MF feeding tube was pulled because it was intact after the fiasco I just wrote about, and I was in another room…

I was in a room getting some basic education about our vents and learning the importance of inspiratory vs. expiratory breaths, basics about Tidal Volume, PEEP, and the modes used on the ventilator to help a patient eliminate CO2. The RT that was taking the time to teach me some RT basics felt it would be another way for me to help my Nurse’s — as well as, give me an idea of what I should expect RT school to be like. We started our conversation with me taking notes at about 0330 and finished at 0400. Prior to having this experience, I made sure all of my work was completed and also that the 5 ECG mons were being watched and were stable.

Well, THE NURSE, flustered and frustrated about the MF tube pretty much pointed the blame at me for not being at the Tele station to advise the patient had gotten the tube out. She said that it wasn’t appropriate for me to advance my education while on the job and that I didn’t need to know any respiratory information as an Aide/Tele Tech. I was stunned!  I was upset as well…I am entitled to a 30 minute lunch break although I NEVER take one, my educational moment was the length of a break…I also wouldn’t have participated in this learning process had I felt that any of my Tele’s were not monitored or if the Nurse’s needed my help. They both indicated that they were caught up. Furthermore, if one can’t progress and gain knowledge or ask questions so he or she may apply what is being learned what is the point of entry level positions in the Hospital setting?

I am floored that THE NURSE is so old school she is unwilling to mentor, to take responsibility for her mistakes, and for using me as a punching bag. I definitely feel blitzed again.

A Conundrum…

There have been many changes at my rural hospital due to lack of ficiduary responsibility. One of the changes affected staffing patterns, another change affects pay…we used to be able to mix our vacation and sick time when we had need to use it; and, it was convenient as it operated more like a paid time off system. Now, we have been advised sick time can only be used when one is ill 3 or more days and will only be issued with a Doctor’s note confirming one’s poor health. I am rankled over this because I am ancillary staff and am, due to the new staffing matrix, am getting called off often. I used to not worry as I NEVER call in sick and so using a combination of vacation and sick time I have been able to obtain enough pay to afford my bills, school, and meet needs…but JUST BARELY. Now that I won’t be able to use sick time, I am worried how I will have enough hours to meet my minimum needs like mortgage, insurance, utilities, and food.

This issue seems to follow me, thus I have been in Health Care for 15+ years not really progressing my knowledge or skill level (or educational base) because when this happens I go back to the two or three job parameter which puts my education on a back burner, particularly since I pay for it myself.

I am really, really tempted to write an anonymous letter explaining that I really feel that instead of the implementation of a Vacation or Sick time pool that my company consider “paid time off,” thus empowering employees to use time accrued for their own unique and personal needs. I feel the letter must be anonymous because dissention about the changes has led to many getting “pink slipped.”

I need and value my job, however, I need to survive, also. I am scared out of my mind that with the devaluation of the American dollar that mere necessities will be so far out of my budget because of my employer’s restructuring  that I won’t make it. I get that my firm is a “for profit” hospital, and I am sure there is a budget that must be adhered to so that investors can see a profit margin, but it seems to me that employees stop going above and beyond when privileges and perks are abrasively and abruptly taken away due to no fault of the employee.

If I am forced to go back to the life of one foot in the business world and one foot in health care I worry that I will be so burned out that I will be incapable of demonstrating the work ethic that I have displayed, and thus, give those in the upper echelons of management a reason to criticize my work or pull precious commodities like a .3% raise from me.

I feel that most of the people making financial decisons are not in a place where paycheck to paycheck has importance. They make a set scale and have benes and perks that would never deem it hard for them to meet the necessities. I wonder if they realize that they loose something from each employee that fears for the basics…

When I have a steady and stable paycheck, I am more loyal to the company and less likely to bring my personal worries with me to work, and thus always able to give 110% to patient care and exceptional customer service…

I guess I need to decide if I can word my concerns in a way that can even be addressed and then decided if I should coin my name or allow my thoughts to be expressed anonymously. I feel that anonymity could make it so that the letter isn’t even considered, yet I do fear that voicing my opinion could cost me my job…and is my fear worth loosing a job I love?

Hot and Bothered…

Well, I haven’t worked a 20+ hour shift on only 4 hours of sleep for about 8 years and found that I really LOVE it!!! I must be somewhat of an adrenaline junkie, after all! But a lot happened to pique my interest and challenge me. I worked with deaf Nurse who can’t hear alarms or ANYTHING. I love her to pieces, but we really need to work on our communication! She can’t hear me with my high pitched voice; and I often can’t hear her as I am listening for Tele alarms with diligence. She asked me to input orders and I couldn’t hear every parameter, so I had to ask her the same question umpteen times (yes, I am probably a little deaf, too).

Furthermore, HOTNESS was there. I didn’t expect that my 20 hour shift would include him because I thought he was off for the Holiday’s…but he was there…it is a smiley moment and an adrenaline rush in and of itself to see his face lit up when he smiles or  laughs. I melt a little inside whenever he and I engage in polite conversation…(a rareity because even though I would probably stop crushing on him  if we were friends, I just can’t win him over enough to be anything more than “ancillary staff,” so the awe I have for his beatific countenance has to suffice). The BIG adrenaline rush came when he and I had a brief discussion about how divorce makes too many adults egocentric and the kids, who should come first don’t. THEN it got better!!! He needed someone to brace a patient who had been admitted for a drug overdose…the patient was having seizures and tremors and an ART line needed to be placed.

Hotness can usually get his ART lines in lickety split…this one was a bit more challenging because the patient would twitch immediately after the line was threaded and a flash occurred. So after four attempts at this I devised a better way for my 4″11″ frame and child sized hands to hold the arm of the trembling patient…I sat cross legged on the floor under the arm of the patient. I was able to get a good angle, hold the arm down and the muscles taut…and we had success!

Part of the adrenaline rush I felt came from the fact that I have never seen an ART line placement up close and personal. I got to see how the RT places sutures in the line; the appropriate technique to palpate for the artery then the method used to thread and tie the suture. In addition to the rush from the learning process. I got to be near my idol and admire his work, handsome face, lovely abductor longus pollicus, and chat with him about anything, nothing, and everything. Although I had butterflies in my stomach the whole time (worried I would say or do something wrong) I realized the pricelessness of the moment…I will never have an opportunity to engage idol in this carefree (yet serious) manner again.

Some of the other interesting happenings from this eventful shift…I got to work with one of my favorite Doctor’s — he is thorough and brilliant, he admitted three other patients to our ICU…I was able to complete all of the orders, run labs and their results, and help with patient care. I think this Doc appreciates my work (I am diligent and have a strong work ethic) so he kept asking me to reprint results and do a few things for him as I was running from patient to patient to ensure all cares were completed.

The only moment we had differing opinions about was a peaked T wave. I felt the elevated measurement was high enough to indicate it as a peaked T wave (a sign of electrolyte imbalance) and he felt it was normal…so I was humbled and taught another valuable EKG lesson….

It was a hot night in terms of  all I learned, witnessed, and attempted to do…such an amazing night of learning and figuring out better ways of doing things; with an amazing EKG strip to boot…and although I completed all of my required work, I didn’t get the extra “AnnieC” touches finished..and that is why I am a little bothered…

SVT…Whaaaaat?

The  patient was a 50 year old male admitted for  bilateral pneumonia. He was originally just placed on O2 mons. His oxygen dropped to 83%…and then whammy…his heart rate more than tripled!!! He went from 67 beats per minute to 203. A manual count of the patients heart rate confirmed that he was experiencing an elevated rate that was over 200 beats! The Doctor ordered that the patient be placed on portable Tele monitors in addition to his pulse oximetry monitoring. Furthermore, a 12 lead EKG was ordered. Both my monitors and the EKG confirmed that the paitent was in true Supraventricular Tachycardia. The Doctor ordered adinosine….heart rate dropped to 200, then a HUGE pause with small T waves present…then the patient converted to Sinus Tachycardia with a heart rate of 113 per minute. Slowly….the patient moved from Sinus Tach into Normal Sinus Rhythm with a heart rate of 87.  One surprising component of this monitor (for me) was that the patient didn’t pause, manifest a 3rd degree block THEN convert to NSR…instead it was pause, Sinus Tach, then Sinus Rhythm. More surprising…after 40 minutes sans adinosine, the patient bradied down to a heart rate of 53 beats per minute. I’ve never seen a cardioversion with adinosine take on the precise characteristics that I experienced…I was slammed with other critical patients, so did not have an opportunity to discuss the situation with the Doctor or Nurse’s….but I wonder why the patient bradied so low in such a relatively fast time-frame?– especially since he was given only 6 mg of the drug……When I have more answers, I will share my findings…but overall,what an interesting strip to witness…

Death….

A 94 year old patient of mine was struggling to breathe. He had aspirated earlier in the day. He was full code. Prior to intubation, both the Doctor and the Respiratory Therapist described the procedure to him and asked if he wanted to be placed on a ventilator to help him breathe with more ease. He finally came to the decison to declare himself DNR/DNI  and decided against intubation.  At about 3am, he was had wheezing and was gasping for air. His O2 sats remained 95% but he was definitely in distress. He was placed on bi-pap with a full face mask. This comfort measure didn’t help and made the patient more agitated. So, the bi-pap was discontinued. Shortly thereafter, the patient’s skin became clammy and was starting to mottle. The Nurse’s were trying to predict time of death. The patient was not experienceing Cheynne-stokes breathing; nor were agonal breaths apparent…..just the wheezy, watery sounding breath that is often associated with aspiration pneumonia. I really didn’t think the patient would die. Although there were significant signs that he would pass, I thought it would be later in the morning after shift change; and, I didn’t agree with any of the Nurse’s time parameters. In my 15 years as a C.N.A. I have seen hundreds of patients with the same symptoms live from days longer to weeks longer…so I was surprised that this patient died — especially since the family present expected more family from out of State to arrive later in the moring to say their good-byes to him. I guess the signifant lesson for me is that a prediciton of death is a 50-50 statistic…ultimately, a patient will die when he or she is ready. I am grateful that we didn’t prolong his life and cause any further stress or pain in an attempt to do so. He was able to pass peacefully with his wife and a few of those he loved holding his hand.

A Christmas Miracle?

I was “on vacation”  from December 1st until the 17th. When I returned on the 18th THE NURSE actually engaged me in a delightful conversation. She asked for my help knowing I would complete the tasks at hand; and, she didn’t say in the morning “What did you do all night?” THEN the oncoming shift came in and said: “We are so glad you are back, a lot of things didn’t get done while you were out, we didn’t realize how much you do to organize the unit!” I felt vindicated!!!!

Ugly Tree x Infinity…