Week 9 Check In

The week 9 reflection covers different patients seen during shifts from March 12th to 14th and 17th to 18th. Cases include a six-year-old with upper GI bleed, a 66-year-old with pneumonia and AFib, an 83-year-old with BP fluctuations, an 82-year-old post-ICU with respiratory issues, a patient from a past trip, and a 50-year-old with sepsis. Challenges include patient preferences, medication management, emotional family situations, and medical complexities. Learning experiences include managing diverse patient needs and ensuring thorough care and communication. So, this is the week 9 reflection. It's going to be covering the March 12th to 14th and 17th to 18th shifts that you'll see kind of in the corresponding document here. This year, we had eight unique patients over the course of the three shifts, although one of those was a night shift. And just different neat things that kind of popped up. So, the first patient that we had was a six-year-old male, R1, in with an upper GI bleed from esophageal CA. Quite a cantankerous fellow. One person assessed, he was urinal bed 10, G2 feeds, and he also was on a heparin drip. But he very much did not want students in the room. And I think he said he would tolerate me because I was a paramedic previously, but he really didn't want anybody else. But he didn't actually tell me this. He told Sarah this, and I learned this after the fact. He was basically trying to poop and hadn't pooped in a number of days. So, we were watching that and doing full bowel protocol with him. But his BP is pretty soft and, again, with that heparin drip. So, it was interesting because of the bleed, like watching everything that you need to monitor. And with him, we had been trying to get lactulose on board for a number of days, too, and he was cantankerous about it. So, yeah, the other thing with him was he knew when his pain medication was being administered, or it was Q2 hours, and he would time it. And 16 minutes before it was due, he was already bugging you about it. So, just social management and learning to deal with patients who may or may not otherwise want to deal with us. My second patient was a 66-year-old female, M1 infernal pneumonia with ACS. She had had an MI that was an NSEMI, and then was also newly diagnosed AFib. She also had no BP, her blood work on the right arm due to mastectomy, and was just quite nauseous, quite in pain. I based an amount of management. She was also full-risk and on continuous cardiac monitoring with prolonged QT. She was, again, new AFib with RVR, and tacky with PVCs when we did have her controlled at that AFib. She was also on an Amiodrip, which was really interesting to kind of feel that and see it managed, and just an interesting patient for overall monitoring. My third patient was a 83-year-old male, M1, who had had falls at the nursing home. He was plus, plus, plus confused, and it looked like that the falls were coming from BP drops. His BP would, like, drop to – gosh, I don't remember when I found that. It was, like, 80s on 60s, and then all of a sudden, he would come up and be, like, 200s on 130s. He was doing these wild swings, and we couldn't even get an orthostatic BP for him standing up because he would just, like, drop into his boots. And he kept pulling his lines, so I resided the IV on him three different times in the course of the two days that I had him. And even with the, like, burnetting over top of it, and it taped down and wrapped, like, it was – he was quite a challenge. And I came in one time, and, like, there was just blood everywhere from his IV, so it's just – he was a fun patient to manage. And then this is the one that Sarah and I had a conversation about midodrine and knowing what meds are for. I had made the dumbass assumption that it was, like, hydralazine, and thanks flipping God that nothing ever happened. But, yeah, we definitely had a good conversation surrounding that. And there was – I would say it's in your myth, not necessarily anything more than that, but it was a good awareness check for me. And ever since then, I've been a lot more diligent about just making sure that even if I think I know the category, that I double-check and make sure. Nothing like that has happened since then. Thankfully, my med knowledge is pretty decent otherwise. The four – I don't remember where we were at. The next patient I had was an 82-year-old male, R1, inward pneumonia, post-ICU, pneumosepsis, with hypoxia and, like, respiratory failure. He was also trying to do, like, VRI and RTP rule-out, so interesting contact droplet precautions with him. He was a fairly new admit. He was also the one that – he was in California and ended up in hospital and ICU there. They medevaced him back to Canada, and we discharged him the next day. So it's the biggest thing with him really wasn't even his care. It was a discharge. His wife was really upset. He needed a walker for at-home use. And it was the day that we had a big fiasco. The wife really didn't want him to be discharged. She wasn't ready for it. She didn't have the home care supplies. She didn't even have clothes for him in the hospital. And the wife came up to me and just started, like, freaking out and having a breakdown in terms of, I can't take him home. Like, I'm not ready for this. This is all on my shoulders and just so much more stuff. And I – for one of the first times, I actually was like, I don't know how to handle this. Like, she wanted to buy a two-wheeled walker from us to take home. She was like, I'll leave my credit card as a deposit, and I can bring it back in 24 hours. And it's like, that's not how things work in Canada, unfortunately. And as an aside, physio yesterday on shift said to me about their just starting to sell some two-wheeled walkers, like they did crutches. But that wasn't a thing in this conversation with the wife. So learning to manage her. Sarah's funny. She's like, I'm sorry that you've had all the, like, upset families. And just another thing to learn about how to manage people who are in a highly emotive state, and they don't think that it's anything I've done in this case. It's just the situation for her was a lot, and she wasn't prepared for it. So trying to manage her. And then once she'd been managed, trying to do the discharge teaching and the ABS and making sure that they were going to be safe. The final funny thing with them was when she was heading out, she wanted me to go stand downstairs at the front door until she was able to go get the car and bring it down. And I just sort of thought to myself, ma'am, like, your husband is 82 years old. Like, he can sit in a wheelchair at the front entrance of a hospital for five minutes on his own. It's going to be okay. But didn't say that. Obviously had more compassion in the moment, but kind of had a chuckle to myself. And I know that if it was my dad or anything like that, I would be pretty involved and pretty upset. And I did relate, because when my dad was discharged post-hip fracture, they gave me about two hours' notice. And trying to organize Genesis and get all the stuff from Call Home Health in that time and get handlebars installed in the toilet, which I'm not that handy. And my brother is not that around. So, yeah, it was stressful. So, I mean, I understand what she's going through from that perspective. The next patient I had ended up being somebody that, as I sat and did research on him, I thought, geez, this name sounds familiar. And right away told Sarah that I might have a conflict with the patient. Turns out this 46-year-old male who's R1 in with seizures is somebody that 26 years ago I went on a trip to Turks and Caicos with and was a part of the Alberta Child and Youth Health Network and my cancer community with. So, really wild. That trip to Turks and Caicos was also a cancer kids' trip that we were sponsored by a Toronto school to go on. Anyways, yeah, the care for him was interesting because there was just a lot of different stuff going on. And in this case, I did ask him if it was okay that I stay caring for him. I did kind of a little bit of a talk at first about, like, if this wasn't ethically okay with you or if you're uncomfortable in any way, let me know. Like, obviously, I'm not going to do anything in case if you're not comfortable with. But if because we know each other from so long ago, you don't want me to care for you, I completely understand. And, like, I can have another nurse second. He gave his consent, and then the family, he had told them that I had known him previously by the time I met them, and they were quite happy to have somebody else who was a cancer survivor caring for this gentleman. But he had a lot going on as far as care-wise. There was also query about, like, methadone toxicity, so we had completely cut him off pain meds medically. And he wasn't really showing any signs of withdrawal, but there were comments made, so I knew that he was kind of suffering, so watching for that. He also had been NPO because of some scopes that we're doing, and he had, like, ultrasounds, and there was a liver biopsy and just lots of other things going on with him medically. In this case, it was interesting because, since knowing him, he felt more comfortable asking me for things, so they became a little bit more demanding of the family, which was, again, an interesting learning opportunity. Lots of regular care things like PBRs, neurovitals. In and out, he was diabetic, so checking for blood sugars, kind of all that good stuff. I ended up having him a number of shifts, but it was neat to sort of get to know him more. The final patient I had was a patient from the previous tour who was that 50-year-old male, our one with sepsis, who was a sepsis versus CML rule-out previously. He, again, was still having acute pain crises. He still had the swollen lymph nodes. His hemoglobin was absolutely destroyed. His platelets – this is why I think I was remembering the blood in the last time. We did end up giving him blood this year. We gave him platelets and – or, sorry, gave him Packard blood cells, pardon me. And so Sarah and I had a really good conversation about that. We hadn't really done blood since the start of my final focus, like, back in January. And I remember Sarah writing down, like, for the first five minutes, for the next, like, ten minutes, and then at the 15-minute mark, blah, blah, blah. And her writing it down – I think I had talked about this stuff with Allison at one point, but just seeing it on the whiteboard made such an impact on me, that one shift, that as we started doing this stuff again and I did look it up, it was a lot more easily accessible in my brain, just from having been able to read it on a whiteboard. The patient ended up needing a muscle biopsy, and there was lots of stuff going on with him. So it was just a neat care day as far as being involved and getting to look at procedures that maybe I haven't really otherwise. He also – like, his blood counts were just all over the place. So watching for when we would get in touch with somebody, and again, I had to keep fighting for pain management until he was maxing out his orders and just kind of going from there. Yeah, I don't know really what else to tell you. It was another neat tour. The March 17th and 18th shifts were both night shifts with Allison, and really there wasn't – I mean, there was lots of care stuff going, but there wasn't a ton to comment on. I think the two biggest patients to comment on are one that is a 66-year-old female. She's an R1 – or she was an R1 with pneumonia and AFib. She's been on this unit for quite some time. I've actually cared for her previously on the clinical. First name Myra for Allison and Sarah. She has an interesting psychosocial history there where there's definitely some – I don't know if it's dementia, but some alterations of cognitive function. Her GCS definitely fluctuates, but she almost has recessed to where she mentates between a 6-year-old level but then comes back, and I don't know if it's all psychosocial behavior or if it's more than that, but she doesn't always understand, doesn't follow orders, and again, with that fluctuating GCS, she can be sometimes hard to manage. There's also some paranoia and lots of refusal of care, and she also pulls out her IVs all the time. She is another one. I've poked her so many times to recite IVs. It's not great. She had been having incredibly high BP, so with her, there's the hydralazine stuff that we were watching, and for a new piece, there was – frick, I hate to say this, my name – bisoprolol, and we had to – the order was for her rate of greater than 140 with an ECG confirming that she's an AFib with RVR, which was kind of a neat order set to see because I hadn't seen one like that yet. She had been refusing all her PO meds, so with me, it was like trying to use Sharky and the dog from Blue's Clues – is that Blue? – to try and get her ticks off, so I would do stuff with Sharky. Honestly, I treated her a lot like I would a pediatric patient. I would do stuff with the doll and show her it was okay before I would do it to her, and then she was a lot more compliant. I had some trouble getting BPs with her, so I did BPs on the forearm, and it worked. I also had to do a BP on her leg at one point because that's just where we were at, but total for care needs and just a really interesting patient overall. She also had a triad because of a pressure injury, and yeah, that was neat, trying to get her to manage that stuff along with all the rest of it. My other patients, there was like CWAS. There was some other stuff doing, but nothing that really makes anything jump out, except for one patient who was a Spitfire 66-year-old male, R1, with alcohol withdrawal and sepsis, query pneumonia, and every time I would go into the room, I would get told like, fuck you, I'm going to punch you in the face, and like this and that. It really made me laugh. I did feel for this guy, but I obviously knew he was withdrawing, and it didn't really faze me, but he had been getting a fair amount of CWAS. It had been like between 10 and 18 when I had had him, and yeah, just kind of mentoring care with him. He liked to come up and try and jerk and punch, but he was quite well restrained. The thing with him was the Q15 restraints because of how many he had there, so it was just a little bit busier of a night of wandering around. Yeah, I guess that really is it to say about the two nights. Time management has definitely gotten a lot better. It doesn't feel busy anymore. In fact, Gabby was also on these nights, and we got to chat, and kind of go through our patients together because of it being that common. Like there was no caregiving sacrifice. There was no task getting sacrificed. Everybody else had kind of been checked in, and nobody needed anything from us. So yeah, neat chance to be able to kind of collab with a colleague on the different care things. I don't think I've had that really yet in the shift, so that was neat. Yeah.