Sunday nightshift
Jan. 24th, 2021 10:17 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
whitewriterThe case for proper IV drug use programs.
Bed 29.
41 yr old male
on a program where he receives a metered s/c dose of buprenorphine weekly on Fridays.
This manages him fine through until Tuesdays, where he then feels withdrawal until Wednesday or so, and will find street fentanyl (supposedly 100mg) or heroine to tie him over until the Friday.
For the past year he's had a fungating ulcer to his L) upper forearm that he hasn't gone to get treated.
Until Saturday when that fungating lesion burst open whilst he was driving his car; : and in the process, exposed his brachial artery to which it must have ulcerated through because that burst open and
bled everywhere. Luckily, he was near a police station (no idea why) and they put on a tourniquet (seriously, very fortunate) and made it to ED with arm intact enough for plastics to take a graft from his left leg: vein, and skin : and patch up the exposed/broken artery; debride the fungating tissue, and place a flap.
To give the grafting the best chance possible; and with concerns regarding compliance with instructions; Mr bed 29 is sedated and therefore intubated/ventilated for 48 hours.
Instead of our usual Propofol and fentanyl regime he's on prop and morphine + dexametomidine(precedex) to try and keep him calm.
Side effect of sedatives include hypotension; necessitating the need for vasopressors and herein lies the conundrum: perfusion to the graft may be compromised by vasopressors who shunt blood from peripheral circulation to central circulation; however maintaining MAP >65 will assist with perfusion of the graft - but sedation is required to keep his arm in the perfect position; and here we go in a circle again.
They were initially using metaraminol instead of noradrenaline . But it too causes vasoconstriction - and arrhythmia's-- and arrhythmia's is also a concern with the precedex so both going at once is probably not a great idea.
Mr Bed 41 requiring street drugs due to withdrawing 2 days prior to his weekly dose is a failure of the system to adequately treat his habit; or manage the reasons for his addiction (for which I have no idea).
As someone who has never taken a drug other than paracetamol (other than one time I had a general anesthetic for wisdom teeth removal) - and even post operatively, still didn't take anything- I couldn't imagine the thought process that leads someone to inject themselves with what is literally: unknown substances. (100mg of fentanyl injected straight will render a human unconscious; likely not breathing: doses come in mcg normally for starters, 500mcg is a lot; I digress). The programs keep these people going on the edge. Teetering in existence until necrotizing facisitis requires an ICU admission and months long in hospital; or an overdose culminates in ICU admission or death. The cost is enormous.
I care for Mr Bed 41 1:1 at a cost of $6000 AUD a day; not to mention the surgery and - he'll have to be on the wards for some time - and the graft itself is already looking rather iffy - you have to wonder if more of this money was spent earlier on, that this debacle for himself and his family could have been wholly avoided. When I say earlier on I mean, when he was in his 20s or maybe his childhood. Or even now: with his Friday program - should he have been on twice weekly dosing with extra support?
Once again I'm on the tail end of a decades long story. We take care of these patients right at the end of when all else has failed.
I'm sure I've mentioned this before. The worst thing about caring for an ICU patient is 4/24 (every four hours), aspirates from an NG tube.
Feeding a ventilated person via a nasogastric tube (NGT) means that if they're feeling sick to their stomach and not tolerating the feeds: they can't verbally tell us, I feel sick.
Instead, we use a 60ml catheter tip syringe and suck out all their stomach contents every 4 hours, and see what's actually in there.
Sometimes I get 700mls of this dark greenish, bilious type fluid that reeks... and smells rather like mild vomit and …. the brand of feed that we use (similar in smell to condensed milk).
Other times I get nothing.
Sometimes nothing means the NGT is up against the wall of the stomach.
Or they're absorbing everything and there's nothing to take.
700mls is a lot. They're clearly not absorbing. Then, GET THIS, so whatever's in there that's 250mls or less: we return down the NGT back to the patient, because it "belongs to them".
I always found that disgusting. It's like eating your own vomit.
I'm so hungry tonight though, that even the thought of returning the NGT hasn't waned my appetite.
Honestly I'd much rather clean up poo.
It's been about 1.5 years since I worked here properly (and even then, that was another unit). So I'm out of sorts a little still.
I check policies before I do anything fearing something's changed that I missed because as a casual, you don't get informed about every change that happens on the floor (you think we should get more informed because we could be here barely at all, and in any of the units at any time).
Things have changed (small things).
I get ventilated patients again (yay).
I'm getting used to the new faces.
People have literally gone on mat leave and come back in the time I've been gone.
I still struggle with the names of those who were rotating (newbies) when I left - who are now more senior than I am taking in-charge shifts in the general ICU.
I'm treated as though I haven't left. The educators haven't done more than say hello. No one's booked me into any of the remedial courses I know I need to take.
It's funny because people have changed roles: the educators aren't the same as a year ago - and I'm still trying to figure out whose who.
Because they forget or haven't realised that I don't know.
It's up to me to check the dates, sort out the paperwork and go through the processes: I should (and do) know how it all works.
It's like going back to high school after a year at university.
Same same but different.
I'm working more than I did when I was at SSH full time and MISH casually - I could barely fit in an extra shift at MISH whereas on 12s I have 4 days off a week: so I've divvy'ed that into 2 casual shifts and 2 days off.
Working more hours but still have 2 days off a week.
Still technically need official approval regarding this but I'm doing it anyway.
It's just as good as I imagined it to be in Nov 2020 when this is what I decided I wanted.
Staffing still haven't figured out that I'm not casual though, and I need to chase this, this week.
Bed 29.
41 yr old male
on a program where he receives a metered s/c dose of buprenorphine weekly on Fridays.
This manages him fine through until Tuesdays, where he then feels withdrawal until Wednesday or so, and will find street fentanyl (supposedly 100mg) or heroine to tie him over until the Friday.
For the past year he's had a fungating ulcer to his L) upper forearm that he hasn't gone to get treated.
Until Saturday when that fungating lesion burst open whilst he was driving his car; : and in the process, exposed his brachial artery to which it must have ulcerated through because that burst open and
bled everywhere. Luckily, he was near a police station (no idea why) and they put on a tourniquet (seriously, very fortunate) and made it to ED with arm intact enough for plastics to take a graft from his left leg: vein, and skin : and patch up the exposed/broken artery; debride the fungating tissue, and place a flap.
To give the grafting the best chance possible; and with concerns regarding compliance with instructions; Mr bed 29 is sedated and therefore intubated/ventilated for 48 hours.
Instead of our usual Propofol and fentanyl regime he's on prop and morphine + dexametomidine(precedex) to try and keep him calm.
Side effect of sedatives include hypotension; necessitating the need for vasopressors and herein lies the conundrum: perfusion to the graft may be compromised by vasopressors who shunt blood from peripheral circulation to central circulation; however maintaining MAP >65 will assist with perfusion of the graft - but sedation is required to keep his arm in the perfect position; and here we go in a circle again.
They were initially using metaraminol instead of noradrenaline . But it too causes vasoconstriction - and arrhythmia's-- and arrhythmia's is also a concern with the precedex so both going at once is probably not a great idea.
Mr Bed 41 requiring street drugs due to withdrawing 2 days prior to his weekly dose is a failure of the system to adequately treat his habit; or manage the reasons for his addiction (for which I have no idea).
As someone who has never taken a drug other than paracetamol (other than one time I had a general anesthetic for wisdom teeth removal) - and even post operatively, still didn't take anything- I couldn't imagine the thought process that leads someone to inject themselves with what is literally: unknown substances. (100mg of fentanyl injected straight will render a human unconscious; likely not breathing: doses come in mcg normally for starters, 500mcg is a lot; I digress). The programs keep these people going on the edge. Teetering in existence until necrotizing facisitis requires an ICU admission and months long in hospital; or an overdose culminates in ICU admission or death. The cost is enormous.
I care for Mr Bed 41 1:1 at a cost of $6000 AUD a day; not to mention the surgery and - he'll have to be on the wards for some time - and the graft itself is already looking rather iffy - you have to wonder if more of this money was spent earlier on, that this debacle for himself and his family could have been wholly avoided. When I say earlier on I mean, when he was in his 20s or maybe his childhood. Or even now: with his Friday program - should he have been on twice weekly dosing with extra support?
Once again I'm on the tail end of a decades long story. We take care of these patients right at the end of when all else has failed.
I'm sure I've mentioned this before. The worst thing about caring for an ICU patient is 4/24 (every four hours), aspirates from an NG tube.
Feeding a ventilated person via a nasogastric tube (NGT) means that if they're feeling sick to their stomach and not tolerating the feeds: they can't verbally tell us, I feel sick.
Instead, we use a 60ml catheter tip syringe and suck out all their stomach contents every 4 hours, and see what's actually in there.
Sometimes I get 700mls of this dark greenish, bilious type fluid that reeks... and smells rather like mild vomit and …. the brand of feed that we use (similar in smell to condensed milk).
Other times I get nothing.
Sometimes nothing means the NGT is up against the wall of the stomach.
Or they're absorbing everything and there's nothing to take.
700mls is a lot. They're clearly not absorbing. Then, GET THIS, so whatever's in there that's 250mls or less: we return down the NGT back to the patient, because it "belongs to them".
I always found that disgusting. It's like eating your own vomit.
I'm so hungry tonight though, that even the thought of returning the NGT hasn't waned my appetite.
Honestly I'd much rather clean up poo.
It's been about 1.5 years since I worked here properly (and even then, that was another unit). So I'm out of sorts a little still.
I check policies before I do anything fearing something's changed that I missed because as a casual, you don't get informed about every change that happens on the floor (you think we should get more informed because we could be here barely at all, and in any of the units at any time).
Things have changed (small things).
I get ventilated patients again (yay).
I'm getting used to the new faces.
People have literally gone on mat leave and come back in the time I've been gone.
I still struggle with the names of those who were rotating (newbies) when I left - who are now more senior than I am taking in-charge shifts in the general ICU.
I'm treated as though I haven't left. The educators haven't done more than say hello. No one's booked me into any of the remedial courses I know I need to take.
It's funny because people have changed roles: the educators aren't the same as a year ago - and I'm still trying to figure out whose who.
Because they forget or haven't realised that I don't know.
It's up to me to check the dates, sort out the paperwork and go through the processes: I should (and do) know how it all works.
It's like going back to high school after a year at university.
Same same but different.
I'm working more than I did when I was at SSH full time and MISH casually - I could barely fit in an extra shift at MISH whereas on 12s I have 4 days off a week: so I've divvy'ed that into 2 casual shifts and 2 days off.
Working more hours but still have 2 days off a week.
Still technically need official approval regarding this but I'm doing it anyway.
It's just as good as I imagined it to be in Nov 2020 when this is what I decided I wanted.
Staffing still haven't figured out that I'm not casual though, and I need to chase this, this week.
