Camping on Whidbey

 

Knock knock

My patient P was at the hospital last week for meningitis which may have explained his cranky and paranoid behavior the last time I saw him. I took in his am meds and found that the crankiness and paranoia were alive and well. P was really upset about other people he claimed were coming into his room and rifling through his things. He went on for a while and my preceptor did a really good job of listening to him and calming him down. His ankle looks worse; he was diagnosed with cellulitis a couple of weeks ago and has been on antibiotics. He’s still getting IV antibiotics and I helped my preceptor connect his PIC line to the IV pump.

P wasn't in his room – or so I thought – for most of the morning and through the early afternoon. I knocked on his door several times and used the intercom to see if he was in the room. When he didn’t respond, I respected his wishes and didn’t enter the room. Finally, after he missed his 1400 antibiotics and the time for his 1600 IV antibiotics was coming close, I entered his room uninvited. The patient was lying in the bed, hard to rouse and disoriented and absolutely drenched with sweat. His temp was 102.9F and I called my preceptor in. We called the doctor and were instructed to send the patient to the hospital – he may have endocarditis or bacteremia. I really should have gone into the patient’s room much sooner. The other staff had also assumed he was out on an errand or out smoking; who knows how long he might have been in there.

Massacre at clinical

A patient, R, hit their call light this morning and said "I feel wet." Their nurse went down and then I was called into the room. I walked in and immediately saw blood EVERYWHERE. R is a double amputee with a fistula (a huge blood vessel where a vein and an artery are fused to allow mixing) for dialysis in their left leg. R scratched it and the whole thing blew. R's nurse was applying pressure to the fistula. Blood was pooled on the bed and had sprayed as far as the couch across the room, covering everything approximately 120 degrees around the patient. The bleeding wasn’t stopping and the ambulance was called. I helped apply pressure, change the R's gown, and talk to them, trying to ensure R was calm and concious – they'd seriously lost a lot of blood. The ambulance arrived and the patient was taken away to HMC. My nurse and I were in the room for the next hour, trying to clean the blood off of everything. It was like Texas Chainsaw Massacre in there. The patient didn’t have HIV but was hepatitis C+ which is even more concerning as far as transmissability is concerned. We tried to be very careful, but especially in the first few minutes of the crisis there wasn’t an opportunity to grab goggles or gowns. We all checked our clothes carefully and it looked like we had done a good job of avoiding exposure. Although there’s still blood in the crevices of my shoes.

Rock star

 

Turnaround

My patient, T, was really unpleasant for the first two weeks I was at clinical. She was constantly requesting pain medication but refused everything available, she only wanted narcotics. Unfortunately she has a history (and a present) of lots of drug use and the doctors weren’t willing to prescribe more narcotics. The pain clinic refused to see her until the active drug use stopped. We tried to explain this to her, but she complained bitterly about being treated differently from everyone else. She was also incredibly lethargic, even stuperous at times and kept reporting falls (not surprising given her condition). The falls were concerning, but her reports didn’t make much sense (for instance, reporting a fall on steps outside…where there are no steps) and her pain was always a 10 out of 10 and moved from the left side of her back to the right and then back to the left. It all spelled drug seeking to the health care providers. There wasn’t anything we could do except keep offering tylenol, heat packs and ice, none of which she wanted. I would have felt worse about this – and that I couldn’t do more to help her – except that she was so obviously using lots of drugs already.
A staff person found a rock of crack in her room one day and the police were called. Unfortunately the patient was so far gone when the cops got there that she didn't even remember seeing them and it had no affect on her. Not so with the other patients - one of the more active users had seen the cops walking down the hall and cleared out his room and was gone within the hour. It was for the best that he left; he'd just received some disability backpay to the tune of $10,000 and all the staff were concerned about what that would do to the amount of illicit drugs on the floor.

Back to T. A few days later a crack pipe was found in her room and the cops made visit number two. They were actually really cool about it and gave her some tough love. Really though, what could they do? Her medical condition was too complex for jail, so if they arrested her, T would have gone to a hospital and have round-the-clock guards. A pretty expensive option, particularly considering that she's barely conscious enough to do harm to herself and not likely to cause problems with other people.

I'm not sure if the visit with the cops did the trick, T ran out of drugs, got some really good drugs, or some combination of all three, but she was really pleasant today. She joked with the staff and danced in the hall to make us laugh. She's got a really funny sense of humor and is just so goofy sometimes. I'm so incredibly glad to get to see her like this and get to know her a bit more as a person, not just some drugged-out hopeless case. It's going to make it so much easier to provide good nursing care to her, even when she is stuporous, because I now know who it is I'm caring for.

An artist

One of the patients on my floor - though not one assigned to me - is wheelchair bound and blind and demented. She has zero short-term memory and wakes every morning to discover that something's wrong with her eyes. She constantly yells out: "HELLOOOO?" to determine if anyone's around. If someone does respond she'll ask for a ride to the hospital or complain about an itchy toe or ask for a snack and then promptly forget that someone is there. "HELLLOOOO?"

I guess when she was first admitted she was pretty functional, or relatively functional compared to now where she can do nothing for herself. She used to have a tendancy to smear poop all over her room - the walls, the bed rails, the faucet handles and so on. Give her a minute alone with a bowel movement and it would be displayed everywhere. The staff called her "Poo-caso."