Emerging Dazed and Confused from the Land of Night Shifters

“Dude! I thought you were like dead or married or something! Where have you been?”

Thus I was greeted by one of my more colourful friends when I ventured out in the afternoon for lunch after working 7 nights in 9 days. How do I feel after this (mostly) self inflicted torture? Let’s just say, off. Usually I like to work nights but this time it has been particularly vile because I have been denied my nap during breaks. Due to ongoing construction, the ER nursing lounge is inaccessible, which means that the lousy nap chairs from yester-year are also inaccessible. Without a nap I’m a terrible nurse. I can’t get IVs in, I can’t collect blood samples, the thought of having to catheterize a little old broken hip lady induces terrible sobs of anguish and people asking me ‘how much longer until I see the doctor?’ makes me seethe with uncontrollable, mouth foaming, profanity hurling, stretcher kicking rage. In a moment of shocking desperation, I think I actually fell asleep while trying to get a history from a psych patient. Perhaps Santa will reward us lowly nurses with a decent lounge and some spare stretchers or couches? Unbloody likely.

In any case, I learned that after waking up entirely disoriented and slightly scared at having seen sunlight for the first time in a week, it is best not to acclimatize to the day time world by trolling in a mall full of herds of bewilderbeasts frantically looking for presents. At least lunch was delicious and fun!

Revenge is a Dish Best Served in 57 Minutes

I am firmly convinced that HR departments (at least the one in my hospital) are run by sadistic, soulless evil minions of Satan. After doing four full night shifts in a row, I went to the department to pick up some income tax forms. Now herein lies the dilemma – my shift usually ends at 0700. The HR department opens at 0800. I went down to the department at 0740 to see if some kind soul would just type in a seven letter password, click print and hand me the piece of paper so I could go home, flop onto my couch and dream that I’m a fabulously wealthy traveler. Instead I walked into a room full of people who at first completely ignored me and then proceeded to berate me for being there. I very politely asked if they could kindly print me the form so I could make my train and get some rest before I would have to come back for yet another night. One particular man told me that I would have to come back in precisely 19 minutes to get the form. For a moment I thought he was joking. He was not. I asked him again, this time practically begging. He told me that since the department is not officially open for another 19 minutes, he cannot print me the form I needed, despite the fact that he was logged onto his computer. Clearly, I was going to lose the battle so I retreated to Starbucks cursing under my breath.

In exactly 19 minutes I was defeated but slightly more caffeinated and crabbily asked for my form. And then that malicious troll tells me “2 more minutes”. This was far too much for my over-caffeinated sleep deprived and emotionally labile brain. I started to wildly point at the massive digital clock in front of the department that said 0800 and demanded that my form be print. He then pointed to his clunky analogue wrist watch and said, “not according to my watch”. Standing there for 2 minutes, I watched him calmly sip his coffee and smear icing over his keyboard and thought to myself that I would exact payment from him a hundred fold if I ever got the opportunity. He finally opened the application, asked for my employee number and last name and gave me my form. Feeling livid yet helpless I asked him why he couldn’t have just done that for me 20 minutes ago. “You’re not special enough to break rules for” was his curt reply.

I stormed out of the department, got home an hour later than I normally would have and ate a giant bowl of rice to try to silence the fury within. After a hot shower and a long nap, my encounter with the evil HR troll became nothing more than an irritating memory.

However, on rare occasions, karma works in my favour. On my next set of shifts, the very same troll was in the waiting room and triaged to fast track for flank pain. He looked visibly uncomfortable while I looked positively overjoyed. When I went out to the waiting room to introduce myself and to bring him inside the department, he didn’t initially recognize me. But boy oh boy did that change fast! Normally I use a 20 gauge angiocath – he got a 16 gauge (it’s a much fatter IV needle). He then started to look at me as if he recognized me (and wronged me) but wisely kept quiet. Perhaps he was cursing his dumb luck and was hoping that I wouldn’t remember him. Fat chance buddy. Fat chance. He was ordered 4-6 mg morphine q4h prn. I normally push morphine but for him, I made a cute little mini-bag and let it drip slowly. I kept an eye on him but in 3 hours he asked for another dose. The satisfaction I felt in telling him that he would have to wait exactly 57 minutes for his next dose while watching his face contort in agony and horror was beyond anything I can articulate. After 57 minutes had passed, I took my sweet time in setting up another mini bag. A better person than me would have let the entire thing go. A better person would not have had this to blog about.

So let this be a lesson to evil HR people who don’t take mercy on night shifting staff – vengeance will be sought and you won’t enjoy it one bit!

Even if it is a Quiet Night...

…The wierdos still come out in packs.

Exhibit 1
30 something year old woman comes in presenting with palpitations and diaphoresis. When I get her into her room, she tells me that she thinks someone at a party tried to get her to OD on cocaine at a party two nights ago. I then asked what brought her in to the ER on this particular night. I almost wish I hadn’t because then I wouldn’t have to hear her say that she kept on taking crystal meth at home to prevent withdrawal. *headdesk*

Exhibit 2
50 something year old man presents with midsternal chest pain radiating to his axilla. He got the standard chest pain workup and then asked for the “Jewish Bible, the Christian Bible, the Quran and the Ramayana and Mahabaratha”. Unable to provide him with those texts in the middle of the night, I asked him why he needed them so urgently. He replied that since he’s been a “lying, cheating, whoring, filthy sonovabitch who’s screwed chicks from every religion, nationality and race”, he might as well repent to all the gods before he “kicks the crapper” since no one can tell for sure who “reigns supreme beyond the clouds”. I ran a drug screen on him. Came back positive for marijuana and benzos. Nonetheless, I believe that his request implied some measure of remorse for his past actions, selfish though his motives may have been.

Exhibit 3
40 something year old woman comes in with halitosis that would make a decaying zombie shrink back in disgust comes in for, surprise surprise, dental pain! I put on an N-95 and ask her to open her mouth. Two of her molars are missing. The void left by her missing teeth was filled with puce yellow pus. She said her pain just started “a couple of hours ago”. Right. She tried prayer and crystals to heal herself when her teeth first fell out. I must have hidden my frustration quite well because she gave me a shiny crystal for being a “sweetie pie”. The crystal hangs in the nursing lounge with a set of sharp white teeth attached to it!

It was a quiet night because for almost 3 hours I had no patients – I saw 6 patients in total that night. Good times indeed!

Best. Shift. Ever.

Yesterday I was still trying to recover from my previous night shifts. I couldn’t sleep the night after until 0500 and I was woken up by construction at 1000. After eating a nutritious breakfast consisting of rice and lentils followed by a gargantuan cup of coffee, I parked myself in front of the television so I could let re-runs of Oprah lull me into a thoughtless daze and promptly started weaving in and out of sleep. This continued until 1400 when I finally drifted off into a deep sleep. At 1420, I was once again woken up by an obnoxious noise – the telephone this time. I begrudgingly reached over and answered gruffly only to hear the obviously forced saccharine voice of the ward clerk asking if I could pick up a night shift. Figuring that I probably will spend the entire day zonked out worse than the guy who OD’d on clonazepam, I might as well go in and earn some (time and a half + night differential) cash. Turns out it was a pretty good decision – I was on a float assignment, I had relatively well behaved patients, a doc who was thorough but quick and because I didn’t take a break, I could leave early (or as administration knows – the last break). I got a chance to catch up with nurses that I normally don’t work with and helped play a pre-April fool’s day prank our staff doc!*

*It involved making fake patient ID and putting it up in the gyne area and a fake chart with PMHx including G20P17, untreated STIs and an extensive psych and drug seeking history. It was great watching him run around the department looking for the ‘patient’. Heh heh heh.

The Five Stages of Night-Shifting

Night 1 – Denial
I’ll be fine with a couple of nights in a row. After all, I’ve handled crazier shifts and I’m a professional after all. Plus, the pre-shift fajita will keep me going well into the night! It’ll be alright! :)

Night 2 – Anger
Why the f**k did I ever sign up for this s**t?!? The next ambulatory jackass who rings the call bell for a glass of water will have my steal toed feet kick their ass!

Dr. Bigshot, you’re pissed off because the violent drunk didn’t give a urine sample? Up yours!

Dr. Condescending, I know what haemoglobin electrophoresis is!!! I only did my first degree in biology!

Dr. Turtle, hurry your ass up! You don’t need to know the life story of everyone who walks in. Just write an order for dilaudid and d/c them!

Night 3 – Bargaining
Oh good Lord please please please let the rest of these shifts go by quickly and uneventfully and I promise, I PROMISE, I’ll stop wishing a pox on the houses of completely healthy attention seekers. I’ll also stop persuading people to sign out AMA.

Night 4 – Depression
Nothing matters anymore. Urine sample not collected? Who cares? Lab telling me draw another group & screen for a non-surgical patient? Whatever. Death seems like a preferable alternative to this perpetual nightmare.

Night 5 – Acceptance
I will never work normal hours. This is my fate. Even with a few days off, I’ll be back. At least I can grab a fajita on the way home... or maybe some Thai food... or chocolate cake... or carrot cake...

Must Have Been a Full Moon

The last set of night shifts left me shaking my head at the patients that ended up in the ER.

Exhibit 1: A skinny, wiry 20-something year old man drunk and high was found wandering in subarctic temperatures in a flimsy concert T, hoodie and jeans complete with socks and sandals is brought in by EMS for bizarre behaviour. According to the more stylistically inclined nurses and docs, the sock and sandal sartorial faux pas should have been enough to drag him in for emergency mental health counselling. He was pleasant enough for being drunk and high so after he received the perfunctory saline bolus, he was left alone with a call bell and heated blankets. Approximately 3 hours later, he appears at the main nursing station (at which LOLs are inquiring about their family members) completely in the nude, with an erection that’s covered by a roll of toilet paper. He gleefully asks everyone (loudly) if anyone needs toilet paper. He was promptly escorted away by security while his nurse practically taped gowns on him. Unprofessionally loud laughter ensued.

Exhibit 2: A 40-something man found by EMS sleeping on a park bench with blood oozing out from his arm. He too was drunk but unlike exhibit 1, he was NOT pleasant in the least. He was screaming, swearing and flinging used urinals at security and anyone unfortunate enough to cross his line of vision. After managing to punch a nurse in her thigh, he was put in four-point restraints and got an IV. I pushed in haldol and lorazepam so fast that had he been sober, it would have made his head spin. Nine hours later he sounded like a refined gentleman politely asking me for a glass of water and some ibuprofen whenever I get the chance!

Exhibit 3: Princess Diana shows up again, this time insisting that ‘she’ didn’t assault another man in the shelter she’s staying at. She was brought in by the local police and demanded that those ‘brutes’ at her side be replaced by her royal guards. I was amazed that her delusions for the most part were internally consistent. When she started to attack us after she got a line put in, she too received some haldol. Before finishing my shift, I brought her juice and sandwich and curtsied to her highness. She seemed extraordinarily thrilled with me, which of course made me smile. It’s good to join in on the delusion if it keeps the patient happy until shift change. Besides, I love her killer sense of style!

Exhibit 4: LOM acting ‘totally fucking crazy’ according to mother and grandson. Turns out grandpa had a sweet tooth and managed to get his hands on his grandkids’ hash-brownies. I wanted a sample. Never got one.

After all that excitement, I’m looking forward to having a nice, quiet and uneventful night in my own bed!

Special Delivery at 0230

During yet another night in which I was estranged from my lavendar-vanilla scented bed, I was overhearing two nurses discuss their pregnancies and asking me when I was planning on having a child of my own (not any time soon considering I'm currently lacking a suitable donor for the other 23 chromosomes :P ). I politely excused myself to undertake a frivolous and potentially risky adventure to the 24 hour coffee shop when a slightly crazed man bursts through the doors and screams, "my cousin is in the car having her baby RIGHT NOW!" Sure enough, I see a car outside with a woman whose face is grotesquely distorted with pain and a man looking stricken with panic. The charge nurse sees this and gets into super-nurse mode. He starts barking orders left and right and screams at me to bring a wheelchair. For once I was (slightly) ahead of the game and wheeled one over to the car and opened the door for the woman. Turns out her cousin was right - she was having the baby right now. Right now as in the head was out! The wheelchair was useless. I ran to get a stretcher and some blankets for her. By this time, the paramedics were helping and security was calming down the waiting room. We got the woman on the stretcher - my charge nurse was on the stretcher assessing the situation, the ER doc was barking orders that I didn't hear, the dad was saying something about the water breaking and I was holding on to the side of the stretcher trying to put in a saline lock. We wheeled her into a room just as the the OB-GYN, L&D and neonatal mafia swarmed the room. Within 10 minutes we were admiring a beautiful pink and shrieking baby girl! Some of the patients came out of thier rooms to see the commotion and applauded when they heard the baby crying! Mommy and daddy were crying tears of joy while the cousin was just beaming. The family was quickly taken up to the L&D floor while I was left thinking that nights like this make night shifts worthwhile. The adrenaline rush also kicked coffee's ass in waking me up!

Baptism by fire

Several shifts ago, I walked in feeling good, feeling confident and generally feeling fine about the night. I put away my coat, got out my ID and stethoscope, greeted my coworkers and started walking on over to the assignment board. And that’s when I experienced a moment of asystole and then rapid tachycardia. My name wasn’t paired up with a preceptor. ‘Surely this must be a mistake – the ward clerk made a mistake. This HAS to be a mistake’, I thought in a panic. Unfortunately it was not a mistake. The charge nurse strolled over and told me that the unit was extremely short staffed and she thought I could take on the assignment by myself. Apparently 4 nurses called in sick. Damn flu season.

So I try to pull myself up by my bootstraps and head over to the fast track area (seems to be where I’m usually placed). I have 8 patients and a very worried day shift nurse waiting for me. Report sounds something like this;

‘Curtain 1 is a 33 year old guy came in with coffee ground vomiting. He’s got 2 boluses of fluid and needs a pantoloc infusion started along with another PIV. He’s due for another CBC in two hours and he’s waiting for a GI consult. Keep a close eye on him. Curtain 2 is HIV/HIT positive and came in for query pneumonia. Her sats are now in the low 80s. She’s gonna need help and lots of it. Oh she’s also isolation for ESBL precautions. Watch out – she’s kind of a bitch and may try to hit you or rip of your mask. Curtain 3 is a homeless lady, EtOH abuse, left elbow cellulitis and waiting for an ortho consult to rule out septic arthritis. Her morphine tolerance can rival that of a large baby elephant so keep on signing out as much as you need but keep an eye out for respiratory depression but you knew that hahaha! Curtain 4 is another homeless EtOH abuser and is VERY tremulous. He needs hourly IV diazepam. He’s to be discharged when he stops shaking. Curtain 5 is a lol who’s waiting for a bed in medicine. The resident wrote a shit load of orders for her. My advice would be to start her cipro, ancef and avelox and let the floor worry about everything else. Keep an eye out on her I&Os cuz the resident is really anal about it. Jerk. Curtain 6 is a perforated appendicitis but GI can’t take her right now because they’ve got 3 urgent cases lined up ahead of her. She’s got admission orders so start her antibiotics quickly. Oh and she’ll probably be spiking a fever soon. Do hourly vitals on her cuz she just doesn’t look right. Good luck hon – make sure you ask for help. Good night’.

When that report was finished I wanted to hide in the bathroom and cry. Turns out that between patient transfers to the floor, I went to the bathroom and experienced what could be my first ever panic attack. I was definitely tachy, diaphoretic and vomited. Had I been older, I would have thought I was having an MI. Not a good patient load to start of with when I'm still a newbie. I don’t know how I managed to survive that night – all I remember is that my priority was sticking on high flow oxygen to bitchy HIV lady, getting pantoloc to coffee grounds guy, antibiotics for old lady and perforated api woman while begging admitting to find beds for the ones who were waiting. When I finally got a bed for my perforated api lady, I realized that I forgot to give her Tylenol for her fever. Since Tylenol was not in her admission orders, the medical directive becomes void on the floor. The floor nurse made sure she bitched at me. Funny thing is that I had Tylenol in my pocket and was willing to sign on the chart for it but she wouldn’t let me. Her problem.

Not that I want a night like that again, but looking back on it I got a month’s worth of learning in 12 hours. Sure I needed a stiff drink after that but since it was morning time when I was finished I just crawled up in my bed and tried to forget that any of the night actually happened. My boss is telling me that she wants to test run another independent shift in a few days so I suppose I better I get my butt into gear and get ready. I don’t wanna!

This Really Happened

On yet another night shift, I was sitting quietly in the nursing station at around 0230-ish reading a patient’s Vogue (I had permission and she was sleeping) when suddenly I hear “OH MY GOD! WHAT THE FUCK!?? WHAT THE FUCK??! GET OUT! GET THE FUCK OUT!” All of us ran to the end of the hallway where we see our previously pleasant 65 year old post MI patient in his bed. With another patient in his bed. A woman. Who was naked. It turns out that the woman was very confused (she couldn’t be oriented to her face, let alone the time) and so in her confusion, she stripped, climbed into his bed and then peed on this poor guy! If that happened to me, I think I’d probably have the same reaction. We apologized profusely to the man and tried to get the woman out of his bed. She stood up and with a misplaced sense of modesty covered her nipples but didn’t really mind that regions south of the equator were on full display. It took almost an hour for us to calm him down and we had to assure him that we would keep her bed in front of the nursing station so we would have our eye on her the entire night.

When we wheeled her bed over to the station, she asked ‘why am I here?’ to which another nurse replied, ‘because you stripped and peed on another patient’. She let out a laugh while telling us that we must be confused because she would never do something like that. There you go folks. We’ve been declared confused by a confused old lady.

Shifts Happen

Ah night shifts. Gotta love ‘em. I’ve come to like night shifts because usually they are a lot more peaceful than day shifts. I also happen to like the fact that call bells don’t go off as frequently, giving me more time to document, review charts and getting to know the unit. But night shifts also mean that I have to get used to dealing with some bizarre situations. A typical night shift goes something like this:

1900
I get to the hospital and my first stop is the friendly Tim’s, where the server has my order prepared as soon as he sees me – large black with two creams and two splendas on the side. The urge to get a honey cruller at times is quite strong but I have to begrudgingly walk away. The thought of seeing myself as a patient scares me! I’d much rather be the one who starts the IVs, not receives them.

1910
Make my way up five flights of stairs (again, refer to comments about not wanting to be a patient) and get report from the day shift. At this time, I’m usually praying to any deity that comes to mind to give me a set of patients that won’t ring the call bell.

1930 – 2200
After getting report, I make my around the rooms introducing myself and doing initial assessments. I’m finding that lately I’ve been doing more mental status assessments than before. One patient told me to “fetch some tiger shrimps waitress”. He was on strict orders to not eat anything for 12 hours to prepare him for tests. When I told him this, he looked at me with puppy dog eyes and asked me, “why can’t I get some goddamned tiger shrimps?” I have to restrain myself from asking non-patients questions like, “Are you in any pain?”, “Did you have a bowel movement today?” and “Can I take a look at your feet?”

Oh but wait, what’s this? “Maha”, my preceptor calls out. “New order for Mr. K. We’re giving a unit of blood stat. Get the paperwork ready and lets take a trip down to the blood bank”. So I rush through my assessments, run down to the blood bank, get a new unit of blood, run back up, take baseline vitals and start to hang the blood. That is until my preceptor gently, but firmly reminds me that I need the Y-type tubing a 500 ml bag of normal saline. D’Oh! Off I go to the clean room, get tubing and saline, start to do baseline vitals but remember that they’re already done and hang up the new unit. Since I have to check this patient’s vital signs q5mins, I run out of the room to prepare a heparin injection for the patient next door. Back to do vitals – looking good! Run out for another 5 minutes, give the heparin injection, sign the sheet and run back to do more vitals. Now I have 15 minutes until the next set of vitals. ‘Great!’ I think. ‘Just enough time to get two sets of meds done!’ Finally, his transfusion is finished and he looks a lot better. Goody goody gum drops, I can sit now!

2230-0000
Documenting time – lots and lots of documenting. When I first started, I thought, ‘this isn’t too bad – 10 minutes and I’m done’. What a chump I’ve been. When I first started, I only documented 2 people’s vital signs. Going through all of the assessments for 10 patients gets very tedious, very quickly. Truly, it becomes a struggle to not check email, facebook or another equally insidious site.

0000-0100
What’s this? Peace? Quiet? Calmness throughout the ward? Can’t be. I’m nervous. Better do the first set of rounds to make sure patients are still in bed and alive. This sounds morbid and it is. I hate standing over patients, watching them breathe a full cycle with a flashlight pointed at them. First set of rounds go great, and since (for once), I’ve finished my documenting, I can get started on other jobs. We all start checking various machines to make sure they are working, medication carts are restocked, narcotic counts are done and new narcotic records for the next day are made.

0130-0330.
Its first break, which means that I can now sleep, while the second break staff takes over the patient load. I would have preferred second break (from 0330-0530) because when I wake up, there is only 2 more hours to go! But I’ll take what I can get.

0345-0400
I feel groggy and slightly nauseous from having slept so little and needing so much more sleep. Nevertheless, I grab some fruit and start another round. This time I find a man trying to climb his bedside curtain. “Sir, what in God’s name are you doing?” He looks rather like a feral animal on the hunt hanging from his curtain while I point the flashlight at him. “Get back into bed!” He obliges and I thank my lucky stars that he didn’t pursue the matter further. When I come back to check up on him, I find him sitting up in his bed, shaving himself. In the dark. With a piece of paper. I thought I was on a cardiology floor, not a psych floor. My eyes are on fire so I go back to the nursing station to sit and pray that no one uses the call bell.

0400-0530
The guy who got a blood transfusion is not breathing well. I can hear coarse crackles from the doorway to his bed. Not good. My first thought was that he was having a reaction to the blood but when I went to take a look at him and went to take his vital signs, he was not displaying any telling symptoms of a transfusion reaction. He did not have a fever, chills, pain, fainting or dizziness, or bloody urine (those were the ones I remembered). Also, wouldn’t these symptoms start showing almost immediately after the transfusion? He finished receiving blood a few hours earlier. Coarse crackles were the only new development. I called my teacher over who pointed to the IV pole. “Notice anything there?” she asked. My blank bleary eyed look said it all. “He received 2 units of blood along with 500ml of normal saline all within the span of a few hours. Potential fluid overload perhaps?” I responded to her with a blank bleary eyed look once again before garbling something along the lines of “lots of watery stuff in lungs means Lasix make man feel better”. I’m so smooth. When we went to check his MAR, it turned out that there was no order for Lasix! That meant that we had to get a doctor, any doctor, to give an order for 20 mg of IV Lasix. Calling doctors and begging for obvious orders is one way to wake up. My teacher was visibly annoyed and told me that usually 20 mg of Lasix is a standard order with a blood transfusion. At least we got the order and the patient’s breathing finally sounded normal. Job well done!

0530-0730
A burst of activity and I have to stay awake! We start checking patients to make sure they’re still in bed and if they need to be cleaned up. The nurses on my floor call this the five o clock train because we all line up, take adjacent rooms and start cleaning patients up (if they need to be cleaned). Since its almost end of shift, foleys need to be emptied, I&Os need to be documented, CHF patients need to be weighed, 0600 meds need to be given out and report for the oncoming shift needs to be prepared. I feel myself getting increasingly restless as the clock ticks closer to 0730 because the only thing on my mind is a shower and my soft lavender and vanilla scented bed (courtesy of Downy). But when its finally quitting time, I run out to the train station where I’m greeted by fabulously well dressed people while I look like a smelly homeless person who stumbled across a pair of scrubs. It doesn’t matter because my day (err night) is DONE!