A Swing and A Miss

A good friend of mine from nursing school was recently on Facebook talking about teaching a lab on Foleys to brand new nursing students. Upon reading her entry, my PTSD kicked in, and I started having flashbacks. You see, I almost failed nursing school because of the dreaded Foley cath.

How to place a Foley catheter is one of the first skills we were taught after the basic vital signs. It is probably the most intricate (in my opinion) skill we had to check off on in order to graduate because it is supposed to be a sterile procedure. On day one of nursing school we were all given a "Skills Booklet" detailing the skills we had to master and get checked off on before graduating. You had 3 tries to do the skill properly on an actual patient if you were unsuccessful, you were out. No big deal, you have 2 years to master and check off each skill. RIIIIGHT.

My first semester of clinicals came and went with no opportunity to try a Foley. My second semester of clinicals came and went with no opportunity to try a Foley. My third semester of clinicals came and went with no opportunity to try a Foley. (Do you see where I'm going with this?) My fourth and final semester, again no opportunity to do a Foley until the very last clinical rotation--OB. Did I just hear every nurse on the planet groan? For those of you not in the nursing profession, the 2 hardest types of patients to do a Foley on are pregnant women and little old ladies (LOLs) for many of the same reasons. Things don't look like they are supposed to on either and a lot of the time things are no longer in the right place.

So, my teacher, knowing I still needed to do a Foley calls me into a room with a VERY pregnant woman who is going to give birth in the next few minutes and the baby is in severe distress. There is the doctor, a nurse and my teacher all watching me and they are all saying "HURRY!" No pressure. Nope, none at all. So, I got her cathed and my teacher and I walked out of the room.

"Do you know what you did wrong?"

"Yep, everything."

"Yep."

Strike One.

The next day I get the chance to do another cath. Maybe now is when I should tell you some of the other reasons pregnant women are difficult to cath.

1) they are not in the best of moods
2) the labia is swollen and heavy
3) everything is VERY slippery

I walk into the room trying to look more confident than I felt. I opened my Foley tray, put on my sterile gloves. Got my tray arranged to suit me. Opened the woman's labia to begin to clean the area. And my fingers slipped. Contaminated the sterile field.

Strike Two.

Defeated, knowing I had one final chance and knowing I had only two more days before the end of the semester to do the perfect cath, I went into an empty room and sobbed.

"I guess I really shouldn't count that first cath, that might have been a little unfair. You have 2 more chances."

Reprieve. I went into an empty room with another student and practiced over and over. I felt confident the next time would be the charm.

The next day, I go into my patient's room, take a deep breath and begin the procedure. When I finish, I proudly give my teacher my skills booklet for her to sign me off.

"You contaminated the sterile field."

"What? When?"

"When you put on your gloves, your thumb grazed your arm."

Holy hell, I'm screwed. I have one day left and one more chance left. In a daze, I barely heard her say, "You will have to check off with another teacher, I can only fail you twice." I knew I would never be relaxed enough with her to pass. Maybe there was hope.

My very last day of clinicals I went to the hospital knowing today was do or die for me.

"I'm sending you down to the ER so Mrs. A can check you off."

Mrs. A was only about the coolest, funniest and smartest nursing instructor ever. She was in her 70's and had been an ER and neuro nurse for at least 50 years. Her hands shook like a Parkinson's patient, but she NEVER missed an IV. Maybe there is a chance.....

I go to the ER and find Mrs. A. We wait for someone to need a Foley. I'm praying we find a man who needs one (they are soooo easy.) Nope, not with my luck. Eighty plus year old LOL.

We walk in the room. She in not responsive. We spread her knees and OMG! I look at Mrs. A and we agree that we have to clean her up first. We gathered towels and lots of soap (I looked for a Brillo pad) and proceeded to clean her up. Next I took my pen light to find to the meatus. Remember what I said about things not being where they are supposed to be?

"I don't see it."

"Neither do I"

"So what am I going to do?" I say with panic in my voice.

"Just try where you think it should be."

Poke. Not there. And now I've contaminated the Foley. I hear the umpire whisper, "You're out, you're out."

"What do I do now? Can I go get another tray and try again?" I know my voice is a shaky whisper.

"Don't worry with a new tray, there is no way we are going to be able to do this sterile. Let's just do it. I'm going to stick my finger in her vagina so you know that isn't the right spot. You just poke around until you find it."

When we finished, she asked for my skills booklet and checked me off with her shaky signature.

Coolest nursing instructor EVER. She knew I knew HOW to do a Foley. She also knew sometimes you can't go by the book. More importantly she knew sometimes you need some help. That is the most important skill to master in nursing. Knowing when you need help and asking for it.

That was 3 years ago. I'm happy to say that she is still working in the ER and she is still teaching.

Why is this soooo hard?

Conversation with a patient with low back pain:


Me: You have a couple of options. If the pain is not severe, I can make you an appointment to see an Orthopaedist in a few days. If you can't take the pain anymore, there is an emergency clinic that is open until 9 tonight. Both options will only cost you your $20 co-pay.

Him: Well, why did the hospital charge me $400 when I went to the ER?

Why did you go to the ER?

I had a bug bite.

You had a bug bite that resulted in a severe allergic reaction? Trouble breathing...throat closing...?

No, it just itched

If you go to the ER and it's not an emergency, your insurance doesn't pay. You have to pay.

Well, what is an "emergency?"

An emergency is where you are in danger of losing your life or a limb, NOT a bug bite that just itches you idiot!

OK, so I didn't say that the idiot part. But I REALLY wanted to! Why is this sooo hard to understand?

Wouldn't that hurt?

A patient dropped by today to tell me her health history because she was sure would "impale" me....hehehe

Back to work....and reality

As I'm sitting here thinking about having to go back to work tomorrow, I'm reminded of a recent staff meeting I attended. The topic was the recent employee survey. One of the low scores for my department was compensation (come on, who thinks they are being paid enough?) The big issue was the fact that we (occupational health nurses) are not paid on the same pay scale as hospital nurses.

I get 2 10-minute scheduled breaks per day, a 30-minute scheduled lunch break a day, holidays off, 2 weeks a year off, and weekends off.

Do I deserve to make what a hospital nurse makes? Hell no. There are somethings worth more than money.

Irony, con't

Lost a someone today.

Favorite patient of the day

Me: Are you allergic to any medicines?

Patient: Yeah, I'm allergic to hydrocodone.

Are you currently taking any medicines?

I take Lortab for my knees?

You are allergic to hydrocodone, but take Lortab? You know hydrocodone is the generic name for Lortab?

Yeah, but when is says Lortab, I'm not allergic.

*headdesk*

Irony

The reason I love my job, the reason it is so great, is the exact same reason it sucks.

I work in occupational health. I am the only nurse for 500+ employees. I wear the hats of mother, therapist, friend, confidant, sounding board, and nurse. I see them everyday--in the hallways, in the cafeteria, in the parking lot. I get invited to their birthday parties, weddings and baby showers. I see them and care about them as PEOPLE, often friends, not just patients. And I LOVE that about my job....

Which is the reason the past couple of weeks have been difficult.

An employee came to me with left sided facial numbness that she noticed when she was getting ready for work. After examining her, I concluded that she most likely had Bell's Palsy. I called her doctor and explained my findings. The doctor concurred and called in a couple of prescriptions for her with instructions for her to make an appointment in a week. The employee went to her follow-up appointment. Just to be safe the doctor did a CT--she has Bell's Palsy AND a brain tumor (the tumor isn't causing the facial numbness because it is in a different area of the brain.)

Another employee has been struggling with a recent CABG and newly diagnosed cancer. Now he has had a massive stroke.

Some days I wish they were just patients....

Worker's Comp Dos and Don'ts

I know I haven't posted much lately. Work has been unusually busy. I think I can sum up much of the last month with this post.

Worker's Comp Dos and Don'ts:

DO believe the nurse and HR wants to help you if you are legitimately injured on the job.
DON'T think you have to fake an injury to get the help you need.

DO report an injury when it happens.
DON'T file an accident report saying you have been hurting for 4 months, request to see the worker's comp doctor and tell him, "Oh, I don't know for sure that I hurt myself at work. Work just makes me tired, and I want some muscle relaxers."

DO be honest about your injury.
DON'T change your story, and when you are confronted with your previous statement say, "Well, that's not what I meant."

DO see the on-site nurse as soon as possible after you are injured.
DON'T go see your chiropractor and get an "adjustment" and then file for worker's comp when he ruptures your disc.

DO keep all your doctor's appointments.
DON'T tell the nurse you didn't go because "something came up" TWICE!

DO follow the nurse's treatment plan.
DON'T say you need more NSAIDs for your tennis elbow because you spread gravel on your driveway this weekend.

DO realize you have some responsibility in taking care of your body and preventing work place accidents.
DON'T be surprised when the nurse tells you that your knees hurt in part because you are 5 feet tall and weigh 280 pounds.

DO realize as you age shit begins to hurt.
DON'T think you are entitled to a life with no pain (no matter what Joint Commission says.)

I think that just about covers it for now.

All or nothing

I was reading various doc blogs tonight and was reminded of yet another thing I love about not being a nurse is the hospital anymore: the DNR with exceptions.

I had a patient once who's resuscitation status read:

If patient is in respiratory arrest, DNR. If patient is in cardiac arrest, chemical code only, no CPR, no intubation.

I do not understand why doctors won't explain exactly what DNR means. It is an all or nothing proposition.

Don't intubate-if the patient survives they will be severely brain damaged.

Chemical code only with no compressions-the drugs don't go to the heart where they can work.

Sorry, you are either a DNR or not. This is not the kind of treatment you can customize.

Nursing Home Resident Found with Maggots in Eye Dies

In addition to the maggots, Anthony Digiannurio, of Deltona, Fla., was found with an infected breathing tube, a partially inserted catheter and bed sores when he was taken to Florida Hospital DeLand from the University Center West nursing home in November, according to the report.

It was not immediately clear if the death was associated to his care.

A representative from the nursing home said Digiannurio had "constant care from multiple hospice workers and two certified nursing aides at the nursing home."

A) Every staff person who signed that chart or had direct contact with that patient should be in jail

B) "It was not immediately clear if the death was associated to his care." Well, it certainly didn't help.

Times you're glad no one else is listening....

An associate came to the health center with a muscle spasm in her shoulder. So I put some warm heat on her and then preceded to find the knot and massage it out. The following exchange ensued:

Lay down and relax. This might hurts a little. I'm going to feel around a little bit until I find your knot. Tell me when I hit the right spot.

"Oooooo, that's it, right there."

Wow, you're really tight.

"Ahhhhh, that's making my arm go numb. I think I'm starting to drool a little on the pillow."

Am I doing it to hard?

"No, it's starting to tingle."

Ok, I'm going to concentrate on your knot for a minute. Tell me when you can't take anymore.

You ok? Your face is starting to get really red.

"Ooooo no, I'm just fine. Ahhhhhhh, that feels soooooo good."

And then we put on our pajamas and had a pillow fight....

Emergency Department

I was 21 when I paid my first visit to the ED. My parents took me to the local ED at about 2am. I was doubled over in pain and vomiting. You guessed it, kidney stone. I was immediately taken to a room, seen by a physician and given pain medicine--I really don't know what all happened after that.......

The next visit was 18 months later. This time it was my roommate who took me to the ED in the middle of the night. Again, I was doubled over in pain and vomiting. Again, I was taken immediately to a room. I remember a nurse saying, "Honey, I have kidney stones too, and I'm going right now to get you some pain medicine."

A year ago today, I broke my ankle. After arriving at the ED, I was triaged by a nice nurse and promptly taken back to a room. My total time in the ED-- triage, x-rays, MD visit, splinting-- took less than an hour.

And just so you know, all this happened at 3 different hospitals, in 2 different states.

I've only had to go the ED 3 times in my entire life, and all 3 times were emergencies. Maybe that is why my experiences with the ED have been positive.

I just don't understand

A patient comes to the clinic complaining of a fatigue and headache. The person with him says, "he's just not a perky as he usually is."

So, I begin to interview him with the standard questions.

When did you start feeling bad?
This morning.

Where do you hurt?
Back of my neck.

Do you hurt anywhere else?
No

Has this happened before?
No.

Do you have high blood pressure?
Yes.

Any other health problems or conditions?
No.

When did you last take your medicine?
This morning.

What do you take?
2 pills.

Do you know the names?
No. I can't remember right now.

And so on, and so on......

I take his BP and its 188/111. I do an assessment and find nothing else unusual. So I get him to lay down, give him something for his headache, arrange for him to be taken home and called his doctor.

After I do all this, I go back to check on him and take his BP again. It's gone down a good bit.

You feeling any better?
A little.

Any chest pain?
No. You know I had one of those things done to my heart a few months ago (as he points to his groin.)

A heart cath?
One of those things where they go in your leg......

Did they put anything in your heart, a stent?
I don't know.

Did they give you a card to keep in your wallet? (for those who don't know, you usually get a card to carry saying what kind of stent was placed)
(digging around in his wallet) Yeah, this.

Have you been able to remember what medicines you take?
No.

But you did take them this morning?
Yes, but that is the first time in about 2 weeks. I just got it refilled yesterday.

Why didn't you get them filled when you ran out? Are you having trouble paying for them? You know, some pharmacies have some medicines for $4......I can help you.....
No, I don't pay for them, I get them from the health department.

How's your head feeling now? (because mine is about to spin around.)
Well its not as bad as when I have migraines.

*Sigh*

Why in the hell didn't you tell me about the cath, the history of migraines, and not taking your medicine for 2 weeks when I first talked to you? And, how in the hell do you not know what someone did to your freaking heart and what the names are of the freaking pills you take?

Pubic service announcement

It's bad enough I have test your pee, so please get the pube off the cup before you hand it to me.

Potty Training

As if I need one more reason to be happy that I don't work in the hospital anymore......

Just drink like the rest of us.......

One of my regular duties at work is post-accident drug testing. Usually the associate pees in the cup, the negative result shows up within 5 minutes, and I can send them back to work. Usually......

The safety officer pops into my office and says there is an associate who needs a drug test and for me to send him home afterwards, or the safety officer adds as a afterthought, send him back to work if its negative. Weird.

A manager escorts the associate to my office and says the exact same thing, and leaves us to the test.

I smile at the associate and say, "Everything's going to be ok, right?"

I get a sideways glance and silence.

"Please don't tell me you did some weed or something this weekend."

Again, I get silence.

"You know you are going to lose your job, right,"

The associate finally responds, "I know."

"Ok, here's the cup, go pee."

The associate goes to the bathroom, shoulders slumped and a resigned look.

Not surprisingly, the test is positive for marijuana. So, I do my thing to send it off to the lab for confirmation and send the associate home.

A few minutes later the safety officer sits down in my office to tell me the story. The associate dropped nearly $4000 worth of product. When told that there would be a drug test, the response was, "I won't pass."

Apparently the associate had been under a lot of stress at home and smoked a dime bag the night before to relax.

Now this person (who was a really good worker) has gone from making $35K a year (not a small amount in the rural community where the plant is located) to being fired for drug use.

As opposed to name brand?

I called a patient at home today to check on her. She had not been back to work since she got sick on Wednesday.

"Hey, this is the nurse. I was just calling to see how you are."

"The doctor says I have migraines. My mom and sister have them, so they must be generic."

Emergency Conference Call

Emergency conference calls are never a good thing.

Today I had to rearrange my schedule for an hour long conference call. Since most of the people who work in the occupational health department of the hospital are out in businesses, a conference call is a fairly good way to let us all know what's going on.

So here's what's going on. The hospital is WAY over budget. Positions are being eliminated and hours are being cut. Occupational health was less affected than most departments, but we lost one part-time medical assistant, and the office manager got cut back to part-time.

Fortunately the other nurses in the department and I generate tangible revenue. Unfortunately, in the hospital setting, nurses don't generate tangible revenue. No where on your hospital bill is there a line item for nursing care. So, guess which people have had their hours reduced or their job eliminated?

People get irate when they get their hospital bill. Five dollars for a Tylenol! Twenty dollars for an IV catheter! I'm being ripped off! So, they complain. In order to maintain patient satisfaction, the hospital absorbs a lot of those costs.

Well guess what? You are not only paying for the Tylenol. You are paying for a nurse to verify the doctors orders, confirm that you aren't allergic to Tylenol, bring you the Tylenol and assess the outcome of you taking the Tylenol.

You are not just paying for the IV catheter. You are paying for the nurse to put the IV catheter in, keep the catheter patent, administer drugs through the IV, assess the site for infection and infiltration, and disconnect the IV catheter.

Nurses do the majority of patient care in the hospital but they don't get to bill for their services. Maybe hospitals should start to bill per hour for nursing care. Just a thought.....

Dixie Laurel, RN, BSN, COHC.....

I just received a letter in the mail and this is how my name was written: Dixie Laurel, RN, BSN, COHC. Have you ever noticed nurses LOVE to add as many letters as possible after their names? Why is that? Are we so insecure about being "just a nurse" that we feel the need to show the world that we are more?

Pardon me while I rant a minute

I spent a good portion of my day trying to help a patient with her medications. She just got out of the hospital after having 4 cardiac stents put in place. Her cardiologist put her on 4 name brand, very costly drugs. She is a contractor where I work and has no medical insurance. All told, her medicines cost a quarter of her gross monthly salary.

Have doctors never heard of the $4 prescription plan offered by several chain pharmacies? There are plenty of generic beta-blockers, calcium blockers and cholesterol medicines. She says she asked her doctor if there weren't some generic alternatives, and he told her no. Now, I realize I'm not a cardiologist, but surely some of these $4 drugs are just as effective as the pricey, brand-new, shiny drugs.

Of course, pretty drug reps in short tight skirts don't offer you glamorous trips to exotic locations for prescribing generics.