Well, now I am in Las Vegas and working at a hospital that is almost three times the size of my Florida-based hospital. I ended up working there for a little over 8 years before I moved on. As I stated in my previous chapter, each hospital is different. Even sister hospitals are run remarkably different right down to the supplies that they use. You would think that the supplies they used would be more standard to save money on supplies, but who am I to say. I know one thing, this hospital was certainly an eye opener for me. I won’t mention the name of the hospital nor will I mention the names of the other hospitals I worked at, though I am sure an astute reader could figure out this particular hospital quite easily.

This hospital was certainly a game changer for me. The main tower alone held over 400 patients. I was not used to dealing with so many patients. During the heyday of this hospital all of our beds filled up quickly. We had three cath labs running 24/7. The sheer scale was just mind-boggling to me. The two med/surgical/telemetry floors had 3 units each. One floor was divided up into a rehab unit and a orthopedic floor while an additional floor consisted of two intermediate care units(IMC) and two intensive care units (ICU). Another tower housed 6 more ICU wards along with other specialty units. While I was there a new state-of-the-art children’s tower was added. When I and my wife started working at this hospital, it had already enjoyed 50 years of life. What a metamorphosis it must have experienced in those years. At one time they even had two suites that were geared towards the more well to do residents in Las Vegas. Many people believed that the hospital was haunted by many souls/ghosts of long deceased patients. While I don’t know about that, many people spoke of the interesting occurrences that they experienced. Many are very difficult to explain. Since I was not a partner to any of these paranormal happenings I will not discuss them here.

I spent my first three years on the floor honing my nursing skills. While it is true that I was queried about assuming a charge position on several occasions, I resisted the temptation so that I could gain more experience. Because I believe that a charge nurse should be able to handle anything that the unit can throw at him/her. So I had three years as a time frame to reach the necessary level of skill. It is my experiences of the first three years that I will cover in this chapter. I also worked as a charge nurse for five years on the same floor and unit. I will discuss these experiences in the next chapter.

This hospital was a sister hospital to the one I worked at in Florida, so the same computer software was also utilized, so this reduced the learning curve somewhat. However, the charting was no longer written on paper it was entered in the computer. The Medication Administration Record or MAR as it is known also now resided in the computer. So this was quite an advancement. But what I found to be of even greater import was that our Care Plans were now computer-generated and were based on the patient’s diagnosis. You no longer had to do the tedious task of writing your own plans of care and care maps. This is in my mind the most odious and tedious part of nursing school and frankly, I feel useless part of it. I feel this way because doctors have the final say on what happens to the patient and how they are cared for. The rest of the nonsense we do is just window dressing. I know that these care plans were an integral part of legitimizing the nursing profession they are a necessary but albeit useless part of modern nursing. This is the case because Medical Doctors don’t take nursing as a profession seriously. We are simply as their assistants, to only be heard from when addressed by our superiors. I know this trend may be changing , it however, is still all too prevalent. Since I like to be complete when I write anything, I will discuss it a little more in depth in the following section.

A nursing care plan (NCP) is a formal process that correctly identifies existing needs and recognizes potential needs or risks. Care plans provide communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the nursing care planning process, the quality and consistency of patient care would be lost. Nursing care planning begins when the client is admitted to the agency and is continuously updated throughout in response to the client’s changes in condition and evaluation of goal achievement. Planning and delivering individualized or patient-centered care is the basis for excellence in nursing practice.

The following are the goals and objectives of writing a nursing care plan:

• Promote evidence-based nursing care and to render pleasant and familiar conditions in hospitals or health centers.
• Support holistic care which involves the whole person including physical, psychological, social and spiritual in relation to management and prevention of the disease.
• Establish programs such as care pathways and care bundles. Care pathways involve a team effort in order to come to a consensus with regards to standards of care and expected outcomes while care bundles are related to best practice with regards to care given for a specific disease.
• Identify and distinguish goals and expected outcome.
• Review communication and documentation of the care plan.
• Measure nursing care.

The following are the purposes and importance of writing a nursing care plan:

• Defines nurse’s role. It helps to identify the unique role of nurses in attending the overall health and well-being of clients without having to rely entirely on a physician’s orders or interventions.
• Provides direction for individualized care of the client. It allows the nurse to think critically about each client and to develop interventions that are directly tailored to the individual.
• Continuity of care. Nurses from different shifts or different floors can use the data to render the same quality and type of interventions to care for clients, therefore allowing clients to receive the most benefit from treatment.
• Documentation. It should accurately outline which observations to make, what nursing actions to carry out, and what instructions the client or family members require. If nursing care is not documented correctly in the care plan, there is no evidence the care was provided.
• Serves as guide for assigning a specific staff to a specific client. There are instances when client’s care needs to be assigned to a staff with particular and precise skills.
• Serves as guide for reimbursement. The medical record is used by the insurance companies to determine what they will pay in relation to the hospital care received by the client.
• Defines client’s goals. It does not only benefit nurses but also the clients by involving them in their own treatment and care.

A nursing care plan (NCP) usually includes nursing diagnoses, client problems, expected outcomes, and nursing interventions and rationales. These components are elaborated below:

1. Client health assessment, medical results, and diagnostic reports. This is the first measure in order to be able to design a care plan. In particular, client assessment is related to the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age-related, economic and environmental. Information in this area can be subjective and objective.
2. Expected client outcomes are outlined. These may be long and short term.
3. Nursing interventions are documented in the care plan.
4. Rationale for interventions in order to be evidence-based care.
5. Evaluation. This documents the outcome of nursing interventions.

The information on care plans was provided by the web page nurseslabs.com. So thank you very much for the valuable information that was provided at this site.

Now that I have made all the clinically-inclined readers happy, I will continue on with my narrative. I again was very fortunate to be working in one of the most experienced medical units in the hospital. Several of the nurses had over thirty years of experience. They all seemed to want to take me under their wings. I was just happy that I fit in. I guess my years as a customer service manager played no small part in this process. So it seems that I just naturally found a way to fit in.

While Licensed Practical Nurses (LPN) were not that common in my previous hospital, they were an integral part of the staff at my new hospital. While they are valuable members of our team, they do have limits. Initially, LPN’s in Nevada were not even allowed to start IVs eventually this idiotic policy was eliminated. As part of this original plan, they could not give any medications via the vein or intravenously. With this new program, they were now able to administer some basic IV medications like the anti-emetics Zofran and Phenergan and proton pump inhibitors like Protonix and Famotidine. This change certainly helped reduce the work-load some. They, of course, were still not able to administer IV narcotics. They also could not do the admission or initial physical of the patient being admitted to the hospital. They could, however, take the patient’s history. Our unit was a 36-bed unit which meant that we routinely had 2 LPN’s and 2 RN’s. So we had to cover all the narcotic pushes for the LPN and help with any admits they might get in the night. So, ultimately we were responsible for 18 patients. Needless to say that we were very busy indeed. In the day time due to the increased work load they only had six patients and also had higher RN to LPN ratio, so that they did not have to cover as many patients.

This hospital is located in the middle of the city, so the clientele were certainly eclectic and disparate. In other words, you were never surprised with what type of patients you got. I cared for transvestites, trauma patients, cancer patients, cardiac patients, prisoners, psychiatric patients, overdose patients, morbidly obese (max 900lbs) patients and, of course, your typical homeless patient. This is just a small sampling of some of the patients I cared for. I even took care of patients who had unique personal relationships and even one case of Oedipus Complex issues. Of course, the cases of neglect and abuse were among the most heart wrenching cases. It should come as no surprise to the reader that ill health tends to bring out the worse in people. I will do my best to discuss a large number of these cases in this chapter. So expect it to be a little longer than the previous chapter, after all the previous chapter only covered four months of time, this one will cover three years of nursing experience in a city of over 1.5 million people.

Not only were the patients unique, the staff was also unique as well. It turns out that to work over thirty years as a nurse you need to be a very special type of person. Many of the nurses I worked with have never done anything else. So I have to take my hat off to these individuals. I have almost reached the 20-year mark and I am asking myself how I will keep up with the work. One thing that is amazing is the diversity of training that these nurses and support staff have. I worked with phlebotomists who were doctors in other countries as well as several nurses. I had one telemetry tech who was also a doctor and eventually became a software engineer. Considering that the training for a telemetry tech is only a two-week class, this would be considered a bit of over kill, and a phlebotomist requires no previous training at all. It turns out that licensing and accreditation can be a bit of an issue when you had your training overseas. Is this appropriate, I don’t know? But I do know that not all training facilities and colleges are created equal. So my way of thinking is that you should always treat everybody you meet with respect because you never know what their background or experience and skill levels are. I guess this is also another reason that I fit in so well. I treat everybody like I would want to be treated. I also had the honor of working with individuals from all over the world from Asia, Africa, Europe, Central America, Canada and Mexico and the Pacific Islands. Nursing and the medical field is truly a melting pot of humanity.

There are so many special people I worked with during my 8 years at this metropolitan hospital, and I would like to mention all of them unfortunately I simply don’t have the room. I will, however, do my best to discuss some of the more unique individuals I worked with. A hospital is made up of many different disciplines, if you take away only one of them the whole house of cards comes tumbling down. If housekeeping stops working you will soon have no place to put the new patients because all the empty rooms are dirty and trust me, you need clean rooms. You have no way of knowing what type of infection the previous patient might have even if they were not being treated for them. I will get to a story involving the housekeeping staff in the next chapter. I believe in speaking up for those that can’t speak for themselves. Nothing upsets me more than when the weak or helpless or even animals for that matter are abused or neglected. I will also talk about some of these cases a little later as well.

I developed friendships with many of the staff members some as a floor nurse and many more as a charge nurse. But before I get hopelessly bogged down, let’s refocus on the task at hand. I developed close relations with three nurses in particular. Two were LPN’s whose names were Bobbie and Linda and one RN named Mary. Mary was the embodiment of professionalism. She has forgotten more about being a nurse than I will ever know. I once picked out a random term from Taber’s medical dictionary, a term I had never heard of before, not only did she know what it was she gave me working examples as well. She never took notes in report and she never forgot anything. Even when she did relief charge nurse. Which is truly amazing since you have to keep track of upwards of 36 patients. I had the fortune and honor of being there when she retired. Unfortunately, because of her long history of being a heavy smoker she did not get to enjoy a very long retirement before she succumbed to the ravages of lung cancer. She was a truly amazing individual and a very special nurse who never looked down at any new nurse that came down the pipeline. While I have lost track of both Bobbie and Linda, I am sure that they have since retired, they were truly unique individuals and great nurses in their own rights. They both had the biggest hearts and would literally give the shirt off their backs. Bobbie had a life that came right out of a soap opera and she, however, had a bit of a gambling problem but I enjoyed the hell out of working with her. She never failed to delight you with the stories of her family. Linda had two major weaknesses…she was way too gullible and she also trusted everybody. She would also come up with some crazy stories about her earlier life. I will discuss a few more co-workers in the next chapter. So, now I am finally ready to tell some anecdotal patient stories.

The case of a beautiful spirit.

I have taken care of a lot of amazing patients throughout my nursing career but the most amazing patient I have ever taken care of was a middle-aged lady who had bone cancer. You may ask why she was so special. She had bone cancer of the skull and facial bones. Despite her terminal diagnosis she never let her spirit flag, she was always pleasant no matter how much discomfort she must have been experiencing. The cancer had eaten through the left side of her face and skull. You could actually see part of her brain and her mouth as what remained of her jaw opened and closed. She never had a cross word and was only too ready to share her experiences with the nursing staff. She especially enjoyed talking to the new nursing staff, it was as if she was trying to teach us about cancer. But in reality she was teaching us on how to be human. It has been years since I have given her any thought. I am sure she has long since gone to a better place. She came to mind when I was going through a list of patients in my head that I wanted to discuss in my memoirs. What a better person to start out this chapter with. It is a shame that I can’t discuss them all.

Watermelon Ice Cream, anybody?

The next patient I want to mention delves into the inhumanity that people can exhibit towards the less fortunate. This patient was a simple and harmless individual who had hit upon tough times and had been subsequently turned out to the streets. While Las Vegas can be a great place to live, it can be hell on the homeless population. We have a very high crime rate against the less fortunate. This particular individual had the side of his head caved in by a baseball bat wielded by some bored juvenile delinquent. I frankly don’t know how he survived the assault because he had a dent in the side of his head the size of a softball. He finally recovered after multiple surgeries. One good thing that came of this event was that he was finally reunited with his family on the east coast. On his last day at our hospital, I asked him what he was going to do when he got back home. He said that he was going to sit under a tree and eat some watermelon ice cream. He never once spoke out against the individual that attacked him and he never displayed any anger or self pity for his condition. Another truly amazing person.

What not to do.

One case that I came across should never have happened. It involved a person who received a very caustic IV medication in a peripheral IV site. This medicine which is called Levophed should only be administered in a central line placed in a large blood vessel. This unfortunate person was shipped to our hospital so that we could clean up the mess. He needed multiple shots of Phentolamine mesylate, an antidote to Levophed to stop further damage from occurring. What happened was that IV went bad and the medicine extravasated into the surrounding tissue. By the time we got him, his skin was already turning black. He would require multiple surgeries to get a semblance of normality back in his hand. I am sure he must have been in a great deal of pain. But this person never complained about what had happened to him. I know I would have been extremely vocal.

Oedipus Complex?

While I am not sure if incest was actually taking place between the mother and her teenage son, it certainly appeared to be the case. Every time we went into his room she was cuddled up with him in his bed. It all seemed a little too creepy to me. I, unfortunately, don’t think that he is still alive. He just took too many risks with his diabetes. He would intentionally drive up his sugar levels to get admitted to the hospital so he could get his pain meds. His was a truly sad case and you just don’t know where everything started going wrong in his life.

What people will do in the name of beauty.

My next patient was another confused individual who I think was trying to become a woman, of that I am not entirely sure. His first mistake was to go to another country to get silicon implants in his butt. His second mistake was to give himself injections in his butt cheeks. I don’t know what he was thinking. You can almost guess what happened next, of course, he punctured the implant and got silicone poisoning in his back side. The wound he developed was just amazing. I don’t think it ever healed. He just kept on leaving AMA. I think it had to do with us not feeding his drug habit to his satisfaction. A few years later I found out what had happened to him. He had just performed fellatio on one of his clients, when his client found out that he was a man, and in a fit of rage, he crushed his head with a tire iron. This was another sad case involving a very troubled spirit.

In the name of money.

Of all the cases I have seen, this one is probably the most heart wrenching of all. It involved a young adult who was born with Spina Bifada. He weighed maybe 60 pounds and his mental development was at the most of a 6 month old infant. He was totally contracted into a fetal position and what was worse, he was covered with decubitus ulcers. His family had insisted on taking care of him so that they could receive his disability checks. Obviously, he was not being taken care of. He was so light that there was no reason that he could not be frequently turned to prevent the wounds from developing or range of motion exercises being done on him to prevent contractures. I hope when their time comes there will be a special place reserved for them.

Boy, are you ugly!

This was another sad case where this poor lady was the victim of a dump and run by her family when they came to vacation in Las Vegas. Yes, that does happen. It takes place when a well- meaning family takes a loved one that is disabled with them on the trip only to find out that they are a kill joy and drop them off at the hospital so they can have fun gambling and watching shows. This particular patient was a pleasant elderly lady who was somewhat obese. What she suffered from was an uncaring family, partially due to their having a poor understanding of what it takes to care for an elderly and total care patient. She had a decubitus ulcer the size of a cantaloupe on her back side. In the language of wound care, it was a stage four decubitus ulcer in the sacral region. She had quite a sense of humor which made it even more sad. After I had dressed her wound and cleaned her up, she asked to see my name badge. This is what she said after closely examining it. “Boy, are you ugly!” I just thought that was the funniest thing. I have a feeling that she never recovered from this wound , it was simply too large and she was too high of a risk for septic infection.

Whoopee… that was fun!

While this was not the largest patient that I saw as a nurse, she was the largest patient that I personally cared for. She weighed in around 800 pounds. But after spending any time with her, you no longer noticed her size. She had the most infectious personality imaginable. She was from Alaska and was being taken care of by her boyfriend and his mother. Hers was another truly sad case. She showed me her driving license… she had been a truly lovely lady who had a for real glandular problem. Many people say that they gain weight because of glandular problems, this one actually did have one. I am not sure if they ever figured out to correct it. I am sure that if she did not lose weight that she would have soon passed away. The life expectancy of someone so morbidly obese is typically not very long. Due to her large size she was on a special airflow mattress insert that was powered by two large fans. Three people could turn this patient. You needed two people to hit the fan buttons simultaneously and just one person to move the patient around. It was actually quite fun to do. When the fans were activated the patient was lifted up off the bed by almost a foot. That is why she said “Whoopee”!…she was truly enjoying the ride. Besides what else did she really have to look forward to being in that state.

You did what to what?!

I will wrap up this chapter with one final patient. You may remember that I said we took prisoners as patients. Well, I am sure that you would not be surprised on the things that they do to themselves while in prison. Apparently at some point in time, I am not sure if it is still a thing because I have only seen one case of it, but this patient did something very strange to his penis. Apparently, in order for a male prisoner to provide more pleasure to his male lover who is also a prisoner during their love making, he inserted a small sliver of a domino under the skin of the penis. It provides a bit of a hump that supposedly stimulates the prostate gland during anal intercourse. What they do is to take a domino and carve it to just the right thickness and size and then they make a small incision the skin of their penis and push it in place. Then after it heals back over they are ready to go. Unfortunately, this is far from a sterile procedure and incision site routinely becomes infected. This means a hospital visit is usually in order. This also means that a urologist has to remove the domino, which is followed by several days of antibiotic treatments. This ranks right up with “gerbilling” in the really weird shit department. Really, if you haven’t heard of gerbilling you really need to check it out on the internet.

I think I have regaled you enough with stories for now. The next chapter will cover my experiences as a charge nurse. Trust me, there will be even more interesting and strange stories because now I am being exposed to all 36 patients, so the strange stories are much more prevalent. And yes, there will be one more penis related story…. Whoopee!