Wednesday, December 21, 2011

+4 Epic Crowns of Epicness

Today started with two hours of power tools grinding and drilling on my teeth, and the discovery that dental anesthetics don't work right for me.

Marcaine (bupivacaine) is supposed to be the longest-acting of the local anesthetics a dentist can use. Normally, the standard dose of 9mg is enough to keep a site numb for upwards of eight hours. I got a total of 72mg of the stuff injected into my face, and wasn't allowed to have any more, because that would put me over the maximum daily safe dose. I needed that much because for me, the dentists were surprised to learn, the pain-killing effect stops very suddenly after about 30 minutes. That made for some pretty uncomfortable moments, when I toggled from "doing fine" to "my nerve endings are seared by the white-hot flame of the sun itself," without any stops in between.

In addition to the drill-grinding with its intermittent bunches of ouch, and all the sharp needly drug injections, my visit also involved: two dentists, three assistants, a sculptor, several molds, three kinds of epoxy, two kinds of UV-setting enamel, and some funky little blobs of thermoplastic. It's a really fascinating process if you pay attention. At some point I'm sure it will all be accomplished with 3d scanners and computer manufacture, but I suppose the technology just hasn't reached that point yet.

After all that I've got some temporary crowns installed, which are made of plastic epoxy. They feel nothing like my natural teeth and I'm not allowed to bite or chew anything with them. The permanent porcelain crowns will be ready in a couple of weeks, though, and once I've got those in my teeth will be stronger than ever.

Saturday, December 3, 2011

Levels of care

The hospital is packed with very sick people this week. The ICU is so full it's overflowing, and their overflow comes to my stepdown unit. So we had to put some stepdown patients upstairs on the telemetry floor, and telemetry patients out in general med/surg. This situation doesn't mean the patients get any less care; we're just providing that care in a different section of the hospital.

I tried describing this to a friend who's not a nurse, and she asked what the heck I was talking about. So this is probably a good excuse to explain what these different levels of care mean in my hospital.

Med/Surg (medical/surgical, aka "the floor") is the bread and butter of hospital nursing. They care for all the adult patients who are sick enough to be in the hospital, but are quite stable and don't have critical needs. Patients get a vital signs measurement and a complete, head-to-toe nursing assessment every 8 hours. A floor nurse in my hospital can have up to 6 patients at a time.

Telemetry is like floor nursing but for patients who need special attention to their heart and lung function. Patients are hooked up to continuous ECG monitors that read cardiac activity, and sensors that read blood oxygenation level. Any sudden changes in the readings will sound an audible alarm. The patient/nurse ratio here may be as high as to 5:1.

Critical Care Stepdown is where I work. We get patients who are still stable but too sick for the floor, either because their condition is borderline and requires very close watching, or because they have multiple complicated care needs. We are also the first stop for patients leaving the ICU after their condition has stabilized. Assessments are every 4 hours, instead of 8. Each of us may have up to three patients at a time.

The Intensive Care Unit is dedicated to care of the most critically ill and unstable patients. These are the people who, without care, are in imminent danger of morbidity and mortality. Many are intubated and on mechanical ventilation, or have other invasive devices for life support and monitoring. A specialist physician, called an intensivist, is on duty there at all times. Vital signs and assessments are recorded at least every 2 hours (but sometimes as often as every 10 minutes). Each nurse has no more than two patients to care for, and sometimes must spend her entire shift with just one.

Though the different levels don't all have the same equipment or experience, most everyone is cross-trained to handle one level higher if necessary. That lets us deal with situations like last night, when the ICU was already full, when two more patients showed up in the the ED with life-threatening accidental injuries. Those patients needed ICU beds proper, so to make room, the unit sent their two least acute cases over to me.

Even when physically moved to rooms in stepdown, both my patients remained at the ICU level of care. Relatively low-acuity by that standard still means they were still quite sick. One was intubated and on mechanical ventilation, which we were carefully weaning in order to retrain his own respiratory function. The other was a lady on drips of multiple medications to prop up her blood pressure and heart rhythm, requiring lots of adjustment to keep her vital signs within defined limits.

To make room on my unit for them, two stepdown patients got sent up to the telemetry floor. Nurses up there have all the monitoring equpiment required for these patients, and know what to watch for. A few telemetry patients got sent over to med/surg, on monitors borrowed from elsewhere in the building. And if med/surg were full, any new inpatients from the ED would have had to spend the night in the ER exam room on a stretcher. (Fortunately, we haven't had to do that to anybody this week.)

What still surprises me is that the workloads pretty much even out. A med/surg nurse with 2 assessments per shift times 6 patients, and an ICU nurse has 6 assessments per shift times 2 patients. The ICU nurse has more complicated tasks, but never has to answer a call light. Either way it's a busy twelve hours.