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Nurses HATE to be pulled, because we (although we don't usually like to admit it) have our own little areas of competency.  When you're outside of your area, you feel a lot of stress.  I do neuro.  I've done neuro for YEARS.  If one of my patients gets short of breath, it's usually due to a neuro problem, and I know what to do.  If I'm pulled to another type of unit, I'm lost.  Of course, I have my med-surg experience and education and I'm not going to stand in people's way and ask stupid questions.  But I'm not going to be familiar with where supplies are stored, and I might even need some brushing up on what the supplies are, what they're for, etc.

One day, they scheduled five nurses for my floor, so I got pulled to the pulmonary floor.  I was scared.  I don't like all that gasping and coughing and spitting.  BUT the charge nurse introduced himself and assigned me FOUR patients.  And they could all get up and sit in a chair, and walk to the bathroom, and tell me what they wanted.  VERY different from my patients.  Then, at 11 am, they got another nurse, and I had THREE patients, WITH a tech to help me. 

So, I came back to my floor the next day and I'm assigned six patients.  And this is why six patients is too much:

Room #1 - This person has a major (bad, serious, rare) fungal infection in a surgical site from about three months ago.  he can talk, but he's so sick that he's too lethargic to, usually.  He's on a medicine which is just hell to be on - he vomits ALL the time, he's not allowed to swallow because of an opening between the operative site and his esophagus, so we have a tube sunk down below the stomach to feed him.  This vomiting is a problem because of the fistula, just like swallowing is.  Tube feedings cause diarrhea.  Get the picture?  PLUS he had to have a blood transfusion.  Three units.

Okay, Room #2.  That's a person who is what we call a frequent flyer.  About a 300# person who is in hospital at least once every two months.  He came in, complaning of V-P (ventricular-peritoneal) shunt failure.  The shunt is supposed to take the cerebral-spinal fluid (CSF)  from the ventricles of the brain to the peritoneum (lining of the belly), where it is harmlessly absorbed.  So, they revise the shunt, and then he developed a CSF leak.  he had to have a drain put in to keep the CSF from building up in the space between his spine and the skin.  They poke a hole into the layer of spine that has the spinal fluid, and insert a little catheter.  That runs out the back and lets the CSF run into a little collection chamber that we have to keep in a place so that we don't EMPTY him of CSF but that lets Enough CSF out).  Flat bedrest, we have to move him in the bed (300# remember)?  We have to empty the little fluid collection chamber every hour and measure it, and adjust the height of the collection thing to adjust the flow of the fluid.

And he's VERY emotional and Very dependent on pain meds.  he even has withdrawal symptoms in hospital if his demerol is late - and he gets it every 2 hours!  He also can be very controlling and manipulative.  He threatened to leave the hospital against medical advice last hospitalization.  I went in his room with the "signing out" form and told him I wouldn't stop him, nobody would stop him, sign here and I'd help him take his stuff to the waiting room for someone to come and take him home.  He didn't really want to go home. He wanted us to be upset and call the doctor and make him order more, better, stronger and frequenter pain medications.

Room #3 - this was an interesting one!  A 50-ish year old eprson who had had a blow-out of his/her front tire and drove into a tree.  Fairly impressive head injuries and a lot of injuries from his/her airbag.  Well, the most visible injury was a smashed leg, so his/her attending was assigned in the emerg -- an ortho doc.  He fixes the leg and figures that he/she can go on home.  But he/she's inappropriate in conversation, lethargic, can't pee and vomits continually.  I don't know about you, but I don't think *I* would want to be sent home under those circumstances to see if I was going to collapse from some sort of intracranial bleed.  Lots of phone calls to and from doc.

Room #4 - that was an easy one.  Well, it was TWO easy ones.  Spinal surgery.  Do you believe they do those on an "outpatient" basis now.  They're admitted to hospital overnight, but the outpatient status saves us a little bit of paperwork.

So anyway, the patient who got there 'yesterday' goes home, and I get another one.  Well, it's not considered "Major" surgery, but you can't just go "Okay" and not worry about them, either.  They're in pain, they've been under anesthesia.  If you give them pain medication, then you have to watch to make sure they carry on breathing.  We don't have the personnel to  breathe for our patients -- we're supposed to get them from recovery in breathing condition, but we don't, always.  Plus, my definition of "Minor surgery" is something that happens to someone I've never heard of.

The first patient in this room was a very sweet person who had had the bigger back surgery and was kept for another day after his/her surgery.  He/she was 75 and not that steady on his/her feet. He/she lost balance whilst walking to the bathroom and fell on the floor, with the tech right there beside him/her!!!!!  I had them x-ray this person from stem to stern, and he/she went ahead and went home that day, but that's scary stuff when patients fall down!

After this person left, I got a a different person who'd had surgery for an aneurism.  On a medicine that keeps the blood vessels in the head from spasm-ing and killing him/her. Unfortunately, this wonder drug has a really weird timing thing, where it has to be taken every four hours around the clock ON TIME within like three minutes before and three minutes after the hour. Sheesh!  Try keeping track of three-minute intervals when everyone else is pooping, crying, vomiting, hurting, needing to be cleaned up (people too sick to go to the potty or turn their body in bed don't very often clean themselves) plus giving medicines, looking at lab results.....

Room #5 - This room contained an elderly person who had senile dementia as his baseline. Because everyone else was jumping out of the airplane, this person jumped out of bed and landed on the bedside table. When we get old, our brain shrinks. When this happens, the blood vessels that lie along the potential space between the brain and the skull when we are younger, find themselves stretched across a real space. They are also less flexible. So a good crack on the head can often produce a very severe stroke.

This person was approximately 93 years old, and the whole family were rather difficult for the nurses to deal with. If there was a nurse visible on the floor (and they "laid in wait" to watch for us!) then they wanted the nurse in THIS room, and not anybody else's! After a miraculous recovery, and as he/she was transferred to a nursing home (not on this particular day), his 70-something daughter pulled me aside and said: "You know these things. Tell me the truth: Is my parent going to make it?"

My reply could only be: "I think he/she has done!"

Room # 6- This one was a bit of a heart-breaker for me. He/she's 76 or so, very youthful for that age, and has been very healthy and active.  He/she'd come in with a sort of a "light" stroke, in that only one hand was affected.  He/she had to go for tests, one of which was cerebral angiography.  They put a catheter into the artery in the groin and thread it up into the brain and put in dye to look at the arteries IN the brain.

So, there's a little hole in an artery that runs fairly close to the skin.  Needless to say, this is a situation fraught with interesting possibilities (I once had to spend 20 minutes with the heel of my hand pressed into a man's groin when his arteriogram site bled.  We were WAY overbonded when that was over!).  Also, they've been having stuff stuck up into their brain, so you have to check them fairly rigorously every 15 minutes for a while and then every 30 minutes for a while and then every hour for a while.  See above, for reference to what all else was going on.  Oh, the part that is a bit heartbreaking is that she's got some bad blockages in his/her head and is going to have to have surgery, but they've also discovered some things wrong with his/her heart, as well.  They had to work up the cardiac thing to make sure he/she'll make it through the surgery. So, in the space of just a days time, he/she went from being perfectly healthy (as far as he/she knew) to having had a stroke AND finding heart problems.

And another person that I've been taking care of  (but not this particular day) is almost 90.  Had a very bad stroke, and his/her condition was such that surgery was not appropriate.  Now, his/her breathing is getting dicy.  We want to make him/her DNR (Do Not Recuscitate), but his/her adult child won't allow it.  I am all for saying that there are things that we do because they will help and things that we don't do because they won't help, or because they are futile.  Doing CPR on a person whose brain is "gone" is futile and shouldn't be done.  Legally?  I don't know - that's not my side of things.  So there were discussions with doctors, family, and reps from the ethics department.  That's part of the little confabs that you have to get into from time to time, along with all this other stuff.

So that was my day.  During lunch time, I also have to cover for another nurse, who also has six patients pretty much exactly like mine and in return she covers for me whilst I eat, and more importantly -- sit down!!!!

Well, the punchline was, that, when I came back to my floor after having been pulled to the Pulmonary floor, and got this happy little troup of campers, my charge nurse asked me how my day had been, on Pulmonary floor?  I said "Great, wonderful.  It was very nice.  MUCH better than here."  And she got all pissed at me and said "Well, if you like it there so much, why don't you go work there?!?!"

Well, she ASKED!!

And, no, I didn't pick and choose difficult patients from different days to illustrate my point. This was my group of patients on a specific day. It was a Tuesday. I remember what room numbers they were in, and I can still see their faces. I happened to have this description of this day, because I'd complained to a friend in an email about how tired I was, and wrote this all down to try to explain it.

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