Good nurse, Bad nurse

Given the past popularity of my posts about nurses and nursing, I thought it best to break my week-long posting hiatus with another one. Fortunately, I have two stories to tell.

Overall, the quality of nurses in the ICU is better than on a ward. I assume, not knowing much about their training and hiring, that this is due to the higher intensity and complexity attracting the more intelligent, or at least more driven, people. However, I also assume that the more intelligent and driven of that bunch tend to stick around longer, and that they therefore are the more senior when it comes time for shift assignments. That's the way I explain to myself, anyway, the fact that the midweek graveyard shifts seems to collect the less competent staffing. The weekends are usually more exciting, since there is more of the shooting, stabbing, and generalized looting going on outside that brings people to a surgical ICU, so we get pretty good staff then. Anyway, Wednesday night.

One of our patients is a lot of pain. A very, very bad motor vehicle crash got him in here, sans his legs and with a host of other injuries. So he requires a lot of pain control, but it has been difficult to give him enough to control the pain, while not over sedating him. His English is also not great, so when he needs help, he tends to make loud groaning noises that can, I admit, be irritating.

None of this excuses the fact that Wednesday night a nurse decided to start him on a continuous dilaudid drip, without a doctor's order. And while that did keep him quiet, he was almost unarousable the following morning. Not in hemodynamic or respiratory distress, just very much asleep. In his (the nurse's) defense, the order had been on the chart, but it had been stopped over a week ago. My attending's reaction was simple. He told the nurse to stop the drip, and stated if it ever happened again, he would put the patient on Q1 hr neuro checks, with 1mg morphine injections and 15 minute follow up checks. This would (aside from being a complicated order to write) be a huge, almost constant drain on the nurse's time. Thankfully, that hasn't happened again. Dr. Benedikt's popularity hasn't risen any more with the staff though, either.

The second was a good experience. I was putting in an a-line, only my second attempt ever, and after placing it, was securing the tubing. This involves taping it around the patient's thumb, so as to keep them from pulling it out accidentally. First though, and this is key, the site where the catheter enters the patient has to be covered with a dressing. I had, however, forgotten competely about that step, with the intensity of my attending watching. The nurse angel assisting me noticed this before my attending did though, and rather than letting me look like an idiot, or even helping me out obviously and revealing my idiocy, she just asked "did you want a larger cover dressing?" Though I admit this doesn't prove anything about her ability, this reminder saved the day. Thank you, Florence.