cupcakes

when i got to work today, there was a box of beautiful cupcakes in the fridge from a patient that i had a year ago. the note on top thanked us for all of our care and went on to say that we are responsible for this patient's new outlook on life. "it has been one year to the day, and thanks to you all, i have many more to enjoy". needless to say, at this point there were tears. there are lots of thing that i'm accustomed to hearing on the floor, such as "you're overstaffed" or "you need to be doing your hourly rounding" or countless demands for pain meds and bedpans and water. but thank you? thank you is something that is rare. a kind word spoken about a job well done? an acknowledgement of the fact that i pour my heart and soul into this job? that was startlingly unexpected. it was a good start to a week that i was praying would go well.

1800: lasix and metoprolol were due for a lady in a-fib. since both the drugs lower blood pressure, i got a bp. 80s/40s. not good, not good. maybe the other arm? 60s/30s. very very very bad. manual BP? 70s/50s. three strikes for me. now this patient is (of course) sick and complicated. she was up in the icu for a long time on pressors to increase her BP and has been having an irregular heart rate with 3 second pauses. naturally, she is the one that i am scared of. so i paged the doctor, who told me that she hadn't gotten sign out from the primary team. she suggested that i page the chief resident, which i did.

then i waited.

and waited.

then after 10 minutes, i paged again.

and waited.

and waited.

then i paged the chief resident who was covering.

and waited.

and waited.

by this time it had been over a half hour and my patient is still sitting in the 70s/40s. low blood pressure means not enough blood to the brain, not enough blood to the kidneys, and passing out and coding and dying.

so i thought about calling the attending, but quickly changed my mind when i saw that the attending on call tonight is seriously one of the most frightening people i have ever met.

by this time i was obviously in distress. i was mad because no one was calling me back. i was mad because well-meaning people kept telling me that "she's fine" as if that's some sort of excuse to ignore unstable vital signs. i was mad at my coworkers who were telling me "don't get so worked up". this situation was no longer about the patient's blood pressure. this situation was now about the negligence of the trauma team and brought to mind all the other times that i have felt abandoned and been forced to fend for myself because the doctors were "too busy" to help me. so i turned redder and redder as i do when i'm upset, and one of the trauma nurses went upstairs to the icu to find me a doctor. she came down with the icu resident who knew my patient and thought that she just needed some fluids because of the all diarrhea she was having. i was still mad, but at least a little pacified by the fact that someone was giving me an order.

and then of course, 45 minutes later, the chief resident saw fit to call back. i politely told him what was going on, and asked if he was at home. yes, he said "you know that" (no i didn't). he then barked some questions at me about admission weight and how many liters of fluid she is 'up' for this admission. when i told him that i thought the patient was dehydrated, he told me that she wasn't. i argued my case for dehydration respectfully, bringing up the fact that she was nothing by mouth for 14 hours and having lots of diarrhea. he didn't seem to agree, and told me that she was up 25 liters since admission, and therefore wasn't dry. so i brought up her edema and suggested that her fluid might be in her tissues instead of in her vessels. he didn't seem to agree. i suggested a catheter so we could monitor her urine output. no. i suggested some fluids so we could increase the volume in her blood vessels. no. then came the most horrifying part of the conversation:

he told me to give the lasix.

with a blood pressure of 78/44.

lasix is a diuretic. lasix makes you pee out all your fluid. fluid comes out, blood pressure goes down. blood pressure much lower than 70s/40s is not compatible with life.

i told him that i didn't feel comfortable giving the lasix. he told me it wouldn't drop her blood pressure. i said it would. he said "i've been around for a little while, you know". i said "i've been around just as long as you have". the whole conversation went nowhere, and at this point i just said "ok" to everything that he said until he finally stopped talking.

i didn't give the lasix.

the patient is still sitting at a BP of 84/44. and we are just going to 'watch her' for awhile. because when she starts to have altered mental status we will know for sure that her brain isn't getting enough blood and then maybe we can do something to treat her. until then, it is apparently my job to keep my mouth shut and follow orders. psssh.

so my day started with a thank you and ended with a screw you.

but at least i got cupcakes.