First Code – CPR or hospice care for terminal illness?

20130717-231231.jpg

This 90 something year old man was repeating, “I want to die” a couple days before. With stage 4 cancer (meaning, it spread from the source location), he should’ve been DNR (Do Not Resuscitate). But since he started to lose his mind (he couldn’t answer the 3 questions: name, location, and time), his family members began to make decisions for him (as a Heath Care Proxy). His family was in such denial that it was time for him to pass away. They believed he didn’t need morphine to ease his pain and should remain in full code in case his heart rhythm converted to v fib or v tach (at this point, you do CPR).

Throughout the night, he kept moaning. But his family would only allow him to take Tylenol. Which honestly isn’t enough if you have overgrown cells invading essential organs. And these organs allow you to breathe and circulate blood throughout your body.

After I had given out my morning meds and taken out a foley, I saw a nurse run. The next thing I heard was “999 on 1 West”. I saw 2 nurses with the crash cart wheel past me heading to a room in the next district over. When I saw them wheel the cart into that room, I knew it was him. The nurse there was already doing CPR compressions and someone else got the ambu bag ready. Though it felt like 5 minutes, about 30 seconds later, 2 critical care PAs, 3 critical care nurses, 2 MDs, respiratory therapist, nurse educator, patient care assistants, and all the nurses on the unit were there. The PAs took over the compressions. The pads were slapped on.

The EKG monitor was still on, so I watched it go in and out of v fib and v tach. Nurses made the call out to the attending and the family to tell them to come in immediately. My nurse manager told me to go the next unit over to get the Line Cart. I learned fast that’s the cart with the equipment to do a central line. Inserting a central line would allow them to bolus (or “quickly give”) fluid directly to his heart to increase blood pressure. Without a properly beating heart, the body won’t have circulating blood.

When I came back, I saw that he was also bleeding out from his rectum and abdomen. Cracked ribs and his tap sites from before may be the cause. Regardless, I primed the normal saline line to attach it to blood that we would give to him.

More epinephrine was needed. More flushes. The nurse educator asked if I knew any of the nurses in the room so she can document everything that’s happening in the room. I gave some names and then let the nurse who was taking care of him take over.

After the defibrillator delivered the shock, I heard that sound. That sound was an asystole sound. A solid beeeeeeeeeep. I looked at the EKG monitor and saw a solid line. He was gone. He got his wish.

This happened in 17 minutes.

20130717-231534.jpg

If only he had been DNR and was comforted, he would’ve died more peacefully. He wouldn’t have bled, have cracked ribs, have something tied to keep his tongue down in case of intubation. He died suffering from pain and misery. It could’ve been in peace in his sleep.

Family members may feel guilty if they decide to make their loved ones a DNR. They may feel that they aren’t doing the right thing and that they should do everything possible to save them. But in terminal cases, the focus should switch from treatment to comfort. This increases the quality of someone’s end-of-life care.

In my mind, when I die, I would want to die in my sleep. Peacefully. No pain. Just as living is a part of life, death is too. And we should pass with dignity.

Fried Bun With Condensed Milk in NYC!! Yum!

20130715-234143.jpg
Manna Cafe and the Fried Bun with Condensed Milk

As a kid, I loved eating these fried buns with condensed milk! I only had it once or twice but I couldn’t forget the taste. After coming to NYC and its 3 Chinatowns, I knew I had to find it. The only places that serve it is at Hong Kong cafes! There are two locations to find this gem. And it’s only $3. Woot!

Manna Cafe (as pictured above!)– right off the 7 Train – Flushing Main St Stop
135-05 40th Rd
Flushing, NY 11354

Cha Chan Tang — in Manhattan Chinatown
45 Mott St
(between Pell St & Bayard St)
New York, NY 10013

Monkey: Journey to the West Review

20130715-220943.jpg

When I saw in the New York Magazine that the Monkey King: Journey to the West was showing at the Lincoln Center Festival had rave reviews, I had to see it! I bought the cheapest tickets online ($25) and saw it yesterday.

As a Chinese American, I heard about the story many times, but never knew the whole story. After watching the show, I finally get it.

It drives home the message that

no matter what, you can change it all around.

You can become powerful but if reckless, eventually you’ll be put down.

If you become obsessed with food, wine, and lust, eventually you’ll cause harm.

But you can also commit to change and persist to be different– you believe things are equal, you develop your mind, and your mind is pure and calm.

If you get the chance, go watch it! It’s the best show I’ve seen in New York.

Education Day 2: Communication and Delegation

Today was our second “Education” Day. The first Education Day that happened one month ago covered medication errors and IV insertion. Today, we talked about communication, delegation and the electronic health record.

Communication among the nurses, patients, doctors, and ancillary staff are crucial for good patient outcomes. We communicate to convey  messages to other people. What do you think is the most important part about communication? Take a guess first!

  • Words
  • Body Language (facial expressions, hand gestures)
  • Paralinguistic (the tone; the way that the words are said)

*

*

*

It’s body language, which accounts of 55%. Words account for 7% and paralinguistic accounts for 38%. Body language shows your attitude and shows how you feel.

There are different ways to give and receive information. Even though we spend 7-12 years of our education on learning how to write and read, we spend less than 1-2 years of formal education on how to speak and listen. This is almost counterintuitive, considering that over half of our communication depends on LISTENING to each other.

We broke out into 4 groups and discussed about traits of good listeners vs bad listeners.

Good Listeners:

  • Eye contact
  • Gives feedback
  • Not rushed

Bad Listeners:

  • Interrupts
  • Has a reply or rebuttal before letting the other person finish speaking

Etc, etc, it can go on and on. To show that we care,

  1. Look at the patient in the eye (not at the WOW all the time; let the patient know you’ll ask a series of questions on the WOW so they know you’re not purposely trying to not give eye contact)
  2. Sit down next to the patient to show that you’re not rushed
  3. When they are concerned about something, ask them for more details (especially regarding pain!)

*************

As for delegation, it is something that new nurses struggle with. The most important takeaway messages I got was:

  • Be specific
    • Example: Take that patient for a walk vs
    • Take that patient for a walk for 80 feet. 1 assist with a walker and oxygen is needed at all times. It’s the first time the patient is getting up so take a pulse ox before and after he goes for the walk. When that’s completed, please tell me what happened.
  • Vital signs and I/O
    • “Please tell me any abnormal vital signs that you see. And for these specific patients (congestive heart failure, post-open heart patients, renal), please document intake and output.”
  • Change priorities as needed
    • Some ancillary staff may think that cleaning equipment or doing the bedtime bundle or whatever it is that they are doing is more important than a patient’s change in condition. Sometimes when you say, “please go do a fingerstick stat” or a “EKG stat” or something else that’s more urgent (such as compromised patient safety aka a patient getting out of bed without supervision especially if they want to use the bathroom or go for a walk but forget or don’t want to call you!), the PCA takes their time to do what you asked them to do.
    • It may help to say: “That isn’t important right now. Right now, it’s more important for you to take a set of vitals on this patient.”
  • If there is an isolated problem (they don’t know or just forgot), it is important to address it right away in private (never in front of the patient!!). Sandwich a compliment, criticism, and compliment. If it is a continuous problem (due to attitude or laziness), then still address it but also bring it up to management.
  • Give feedback. Everyone is valued and needed on the unit. Using their name and saying thanks goes a long way.

 

Best Part About Working Over 4th of July

20130707-055454.jpg

  1. Enjoying the Macy’s fireworks with your patients on channel 4.
  2. Enjoying the NY Yankees playing… And the NY Mets.
  3. Less traffic, less patients (who wants to voluntarily go to the hospital on a holiday weekend? Um, no one!!)
  4. More downtime… In general.
  5. Time and a half pay!
  6. Less procedures.

But, you still have to be just as vigilant! Know the emergency call number by heart (no, it’s not 911 at the hospital). It will come in handy when you need it!

Off probation — what does that mean?

20130707-054257.jpg

I’m off probation now at the hospital.

That means I passed the series of “tests”—
doing 2 head to toe assessments,
giving out medications through different routes,
going over the chest tube, suction set up, code master (defibrillator, pacer, and cardioversion),
doing drip calculations and entering into the IV pump,
going over the telemetry monitor, and
taking the 50 question EKG exam and passing with a score greater than 90%.

It means no more checking each narcotic.
And trust me, on an ortho floor, a lot of people are in pain, pain, pain.

It means no more checking insulin units.
Yes, I know how to draw up x units of humalog, lantus, and the like.

It means I’ve been doing this for 6 months.
And that means I got 2 weeks of vacation time!

It should mean that I know what I’m doing.
Although I will keep asking questions. And questioning orders that don’t make sense.

It means that I will begin to float to other units.
I won’t be on home turf all the time anymore.
Other med-surg floors and the ER.
I have to admit, I’m a little scared.

It means that I’m ready — and mostly excited!! 🙂

Donating Stool Isn’t That Weird Anymore

The first time I came across donating poop from one to another was at my hospital. At first I was a little grossed out but then it made sense— all that healthy bacteria one person could have
— and then transplanting it over to someone who lacks the bacteria (especially those with ulcerative colitis) can work wonders. It helps restore a healthy digestive tract!

Read what a New York Times opinionator did to help save her friend by donating her fecal matter.

I’m almost off probation at the hospital!

It’s been 5 months since I started on the med-surg telemetry unit and it’s almost time to come off of probation! One of the nurse educators watched two of my head-to-toe assessments and me giving out medications (satisfying the 5 rights for a PO med, SQ injection, intravenous med, and narcotic).

I remember one of my first nursing school classes– doing the entire head-to-toe assessment in 10 to 15 minutes and stating each finding. That was probably one of the most important classes because it’s now kinda easy to recognize something abnormal.

Especially for a cardiac patient, pedal pulses, edema, lung sounds, heart sounds, and neuro checks are important.

Bowel sounds and asking for the last BM is important for surgical patients or for constipated people.

Skin checks at pressure ulcer points (sacrum, heels, back of head) are of upmost important, especially for bed bound and incontinent patients. Is it red? If it’s red, is it blanchable (turn white when you push it)? Could it be a stage 1-4 or a deep tissue injury?

Surgical sites should be monitored for bleeding, leakage, etc.

Urine output of a minimum of 30 ml/hr is also important, especially for those who have a foley! But even knowing how often patients urinate is important. If they haven’t gone all day, then it’s a problem!!

Anyway, I could go on and on. But for right now, here’s an example where the assessment made a different (and trust me, there are many, many examples).

A patient was having a productive cough and felt like he was having a hard time breathing. His O2 sat was 94% on 2L nasal cannula but his lungs had crackles (it sounded wet!) bilaterally (on both sides of his lungs). His feet were puffy (or +2 edema) although pedal pulses were palpable. After calling the PA, I got an order for IV Lasix — which basically works your kidneys to draw in the fluid and excrete it through your urine. Throughout the rest of the night, the patient continued to cough, but his lungs began to sound better. However, due to his surgical site, he experienced a lot of pain too. While I gave him pain medications according to the orders, I noticed that the patient started to get a little more confused by the end of shift. This is when I had to start questioning the type of pain medication given. When giving report to the day shift nurse, I made her aware of my findings. Because of that, she was able to talk to the PAs, NPs and MDs on the floor who are more readily available during the day and make an appropriate decision to treat his pain without him getting confused.


Anyway, I passed the head to toe assessments and giving out medications portion. Now, there are two sections left.

1) Code master, setting the IV pump, and doing the appropriate medication calculations

2) 50 question EKG test with a > or = 90% since I’m on a telemetry unit. It wouldn’t make sense to work there if I can’t read the rhythms. Even though each month I have to pass a 30 question exam too, they still want us to pass the 50 question exam. It’s ok– I’m ready anytime. 🙂