Monday, March 13, 2006

Two steps forward, eight steps back...

My preceptor and I just don't work well on a professional level. I have come to accept that. This weekend of clinical was very interesting if I do say so myself. I will be the first to admit that I am not a personality for the ICU. Despite that fact, I am trying to make it through this rotation. On to the patients.

My first patient this weekend was a 42 year old man, diagnosed with sepsis. His history includes HIV, hep B, cancer, genital herpes and an assortment of skin conditions that make you itch to think about. He also had a rectal prolapse, a colostomy, kaposi sarcoma, pseudomonas pneumonia and he was a rule-out Tuberculosis. Long story short, he was very sick. When I arrived he was having a broncoscopy done. It was explained to me that he only told his family that he had cancer so to keep the HIV hush. It reminded me of my crazy cousin, and other people I know who live under a veil of secrecy. One of my aunts had HIV and we only found out on her deathbed. It was very sad because she kept herself away from the family due to the shame of being HIV positive in the late 80's early 90's, and we feel like we lost so much time with her.

Like with all of my patients, I felt like I owed this man my personal gold standard of nursing care, even though he was sedated most of the time. I spent at least an hour bathing him. It seemed like a lot longer because I had to wear a duck-bill mask that protected me from contracting his potential TB. Then I lotioned his body down and gave him a fresh gown and sheets. He couldn't speak due to mechanical ventilation/orogastric tube placement, but he seemed to be more comfortable. Most of the time that evening was allotted to suctioning his endotracheal tube, hanging antibiotic drips and putting a saline soaked dressing on his inside-out rectum. What a way to spend a Friday night. And I must add that I had a good night of nursing practice, I really felt like I knew what I was doing.

Then on Saturday night, I had the priviledge of taking care of a patient who was an inmate at a local penitentiary. Despite whatever crimes committed by this patient, I give her the medal of honor because the resident doctors stuck her 30+ times trying to get an arterial line started, all while hand cuffed to the bed by the ankle. That's right, at least 30 times and none of the attempts were successful. If you are unfamiliar with the arterial stick/draw, this is something that hurts a hell of a lot more that your typical IV stick because the arteries are deep within the body and surrounded by nerve endings that are there to cause severe pain so that if you happen to be self inflicting harm, you will stop.

She had a little bit of lidocaine, but it was quite obvious that she was experiencing the sensation of pain. Once she even said, I have a shooting pain that runs all the way to my feet. Do you think that stopped him? Nope. He said something like, that tells me where not to stick next time. Incredible. The patient never complained once but to say, I hope we are getting somehwere with this. The resident finally gave up after over one hour of pokes. He told the patient, I know it doesn't hurt me like it does you, but my ego is bruised. I wonder if he would let someone do an arterial stick on him 30+ times.

The patient came to the hospital, from the penitentiary, complaining of abdominal pain which turned out to be pyelonephritis that had advanced to urosepsis. She had nephrostomy tubes placed in her back from both the left and right kidneys. She also had a a Foley. She had a central line, but because solution had been running through it, we couldn't take a blood culture. On top of that, she had a levophed drip, so we needed to monitor her blood pressure closely so that we could titrate the meds appropriately. These gung-ho residents come into the room intercepting almost any skill opportunity that presented itself.

I was trying to do a blood draw, this guy steps in front of me and proceeds to take over my stick. I was a little heated, but I let it slide. Then of course I wasn't doing the q15 minute vitals fast enough. I took 48 sets of vitals last night and my preceptor was bugging-out because I was late on maybe three of them. She had me running around all night like a chicken with the head cut off. I barely had a break between the patient needing something done, needing to call pharmacy to order meds, paging respiratory, my preceptor yelling at me and the resident asking me stupid questions.

Then I tried to give report. I never am right enough for my preceptor, she always has to add something more to what I say. Very annoying. For instance, the patient was anxious and I explained that the patient stated that she was having an anxiety attack. My preceptor chimed in that the patient had no medicine prescribed for anxiety. I said that she takes Prozac at the penitentiary, and before I could explain that the PATIENT felt it was a medication that SHE felt helped with her anxiety and that she asked for it, my preceptor cut me off and said whatever she said. Basically, the student doesn't know what she is talking about again. Whenever my preceptor does this I shut down. I don't say anything, I just let her do whatever. Only 2 month of this crap left.


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