i am trying to think of a way to say this diplomatically. nope, can't do it. SURGEONS TOTALLY SUCK. ok, so today it was just one in particular. let me explain.
i have a 91 year old post-op patient. this in itself is actually very bad. 91 year olds shouldn't have surgery. please, if i am ever that old and someone wants to cut me open, slap a DNR bracelet on me, cover me with a palliative care quilt and call the harpist to play me into the light. i want this on the record!! unfortunately, this lady wasn't so lucky. she had surgery, then had complications, then her extremities filled with fluid, her lungs went to crap, and she got a couple of infections. Now she has so much fluid in her legs that my handprint stays on her when i touch her. and her lungs are so wet that you can hear her rattling from the doorway. and as all this fluid is in inappropriate places, she is actually dehydrated and has had only a small amount of urine output in 24 hours.
enter me. i came to work today feeling the need to right wrongs. i had the patient the night before, and was concerned about her fluid status and urine output. the on-call doctor that night didn't want to do much because he didn't know the patient. so when i got to work today, i was anxious to find out what was being done.
enter the surgeons. what was being done? ABSOLUTELY NOTHING. now on some level i understand this. we can't give her fluid because it's not going to the right places. we can't pump her full of diuretics because her kidneys can't handle it. we can't cure her because she is 91 and she's probably going to die. but we CAN do something, namely making her a palliative care patient and getting her comfortable.
enter me talking to the surgeons. i really did try. i sat down with the chief resident of the surgical service, the nurse practitioner, the intern, and the med student. i explained my concerns. i went through her edema, her lungs, her urine output, etc. and when i was done, i waited for the chief resident to respond. and what did he say?
"no."
that's right, no. just no. ok, excuse me? what part of what i just said did you not understand? so i repeated myself. the conversation went a little something like this.
-i explained that if the patient is not palliative care, we have an obligation to treat her.
"well what do you want me to do about it"
-i explained that i thought we should make her palliative
"no"
-well then we should really have a meeting to discuss what we're doing with this patient, because there's some confusion and not everyone is on the same page
"what do you mean there's confusion. who exactly doesn't understand."
-NURSING! I DON'T UNDERSTAND WHAT WE'RE DOING. AND YOU OBVIOUSLY DON'T UNDERSTAND WHAT I'M SAYING.
"well what can we do to make YOU happy then"
-i explained that we needed to make a decision about the plan of care
"well i don't understand why you're so concerned about putting a label on it"
-i explained that these 'labels' exist so that we're not passively killing people. and if i don't have such labels, i will treat my patient accordingly. thus when she starts circling the drain, i will call my resources and we will do labs and tests and oh i don't know TREAT HER, because i have no reason not to. i believe this is also when i started throwing around phrases like 'failure to rescue' and 'obligation to my patient'. i finished up by saying that i didn't feel comfortable with this grey area of medicine, and with watching her slowly drown to death. if the surgeons want to kill their patients in the OR, that's on them. but when they try to do it on the floor, thats on me. (ok i said that last part a little more politically correctly, but the gist is the same). then i told them that i would let them discuss things and they could get back to me with their decision.
now this should have felt awesome. and actually, it was very satisfying. i said what i needed to, and i stood up for myself and my patient. i didn't get intimidated, and i didn't back down even when it was clear that i wasn't going to get what i wanted. but i don't particularly enjoy eye rolling and snippy comments and tall bald men in white coats talking down to me. so was i mad all shift? yes. and do i harbor revenge fantasies involving me running over said chief resident with my SUV? yes. and will i add him to my list of people that are not to touch me should i ever need surgery? yes. and i will underline his name.
for the record, i didn't get what i asked for. the patient is still hanging out, not being treated but not officially palliative care. but for my trouble, i got 20 mg of lasix by mouth! i like to think of that as my consolation prize. i'm sure that i also got a reputation as a crazy vigilante nurse. but at this point, who cares? i can go to sleep tonight knowing that i advocated for my patient. and that evil chief resident? he'd better watch out in the parking lot.
Thursday, February 10, 2011
Tuesday, February 1, 2011
rules of trauma
rule: bad things happen to good people. bad things also happen to bad people. however, bad people are invincible, while good people have horrible luck.
case in point: this week i had a normal trauma patient. this in itself is news-worthy. this poor woman is a doctor who was heading home from work. it's 2 in the morning and some drunk idiot is out on the roads in his 3/4 ton pickup and hits her head on. surprisingly, her injuries were relatively minor. or so we thought until we got a scan that showed that she has bilateral carotid dissections. this is very bad, basically a stroke waiting to happen. so we put her on anticoagulants and got a repeat scan after 5 days. i honestly thought that she was going to go home the next day. she was a model patient, up walking and talking, looked great. but the scans were worse. and now she probably needs a stent, which has a good chance of knocking a clot off of her carotid artery and making her have a stroke. or we could leave the artery as is and it could completely occlude and she could have a stroke. see the dilemma?
this is why i am upset:
1. she is a nice normal person just doing her job and she has this horrible accident happen to her. why? because other people are stupid and reckless. you can bet that pickup man is just fine. why? because he is a bad person. and bad people are invincible.
2. she has young kids and they should have a fully functioning mom who is not a ticking time bomb.
3. she might not be able to do her job anymore. she's a doctor. doctors aren't doctors because they want to be, they are doctors because they have to be.
4. i am getting very tired of watching bad things happen to good people. it's just not fair.
counter case in point: another patient, this one not mine. double D from the block. he had the misfortune of getting shot through his liver and still somehow living to drive us all crazy despite having no blood pressure in the field. but have no fear!! gangsters are invincible. double D can continue to manage his drug cartel or do whatever it is that he does from the comfort of the hospital. every night like clockwork, we have what i like to call "D on parade". around 8 pm, all of D's friends and family would show up. the group included 3 baby mamas, various infants and toddlers, aunts, cousins, homeboys...for a grand total of at least a dozen people. despite the fact that D has 2 perfectly good legs, he would sit in his wheelchair and insist on being pushed up and down the hallway for a good hour, obstructing traffic and generally being a pain. as the group walked (at a snail's pace) up our very narrow halls, they would stop at various rooms along the way and pick up other members of the community. note: when you are in the hospital and coincidentally know 2 other people on the same floor who also happened to get shot at the same time as you IT IS TIME TO MOVE. and on it went, sloooooow up the front hall, slooooooow up the back hall. back down to the room. repeat. then someone had the bright idea of wedging a couple of kids in a second wheelchair just to make sure that the entourage really took up all available hall space. this literally happened EVERY NIGHT.
now i realize that this sounds judgmental, and i'm certainly not saying that anyone deserves to be shot. but when you still have a house arrest bracelet on your ankle and i watch your 3 different baby mamas rotate shifts, i am inclined to believe that you are living in a gangsta paradise, and may just have played a small part in your fate. and when you refuse to do any of your own cares, snap and clap at the nurses to communicate your needs, and pee/poop the bed out of laziness and entitlement then insist that we clean you up despite the fact that you are perfectly capable of doing these things independently, i am inclined to resent you.
so to recap: we have a productive member of society. kind, polite, participates in own cares and follows medical instruction. then we have a felon. rude. obstinate. unwilling to do even the most basic things despite the fact that he is perfectly capable.
lets take a guess. who walked out (or was wheeled out by an entourage member, most likely) unscathed, and who is facing a very serious diagnosis with a crappy prognosis?
that's right.
case in point: this week i had a normal trauma patient. this in itself is news-worthy. this poor woman is a doctor who was heading home from work. it's 2 in the morning and some drunk idiot is out on the roads in his 3/4 ton pickup and hits her head on. surprisingly, her injuries were relatively minor. or so we thought until we got a scan that showed that she has bilateral carotid dissections. this is very bad, basically a stroke waiting to happen. so we put her on anticoagulants and got a repeat scan after 5 days. i honestly thought that she was going to go home the next day. she was a model patient, up walking and talking, looked great. but the scans were worse. and now she probably needs a stent, which has a good chance of knocking a clot off of her carotid artery and making her have a stroke. or we could leave the artery as is and it could completely occlude and she could have a stroke. see the dilemma?
this is why i am upset:
1. she is a nice normal person just doing her job and she has this horrible accident happen to her. why? because other people are stupid and reckless. you can bet that pickup man is just fine. why? because he is a bad person. and bad people are invincible.
2. she has young kids and they should have a fully functioning mom who is not a ticking time bomb.
3. she might not be able to do her job anymore. she's a doctor. doctors aren't doctors because they want to be, they are doctors because they have to be.
4. i am getting very tired of watching bad things happen to good people. it's just not fair.
counter case in point: another patient, this one not mine. double D from the block. he had the misfortune of getting shot through his liver and still somehow living to drive us all crazy despite having no blood pressure in the field. but have no fear!! gangsters are invincible. double D can continue to manage his drug cartel or do whatever it is that he does from the comfort of the hospital. every night like clockwork, we have what i like to call "D on parade". around 8 pm, all of D's friends and family would show up. the group included 3 baby mamas, various infants and toddlers, aunts, cousins, homeboys...for a grand total of at least a dozen people. despite the fact that D has 2 perfectly good legs, he would sit in his wheelchair and insist on being pushed up and down the hallway for a good hour, obstructing traffic and generally being a pain. as the group walked (at a snail's pace) up our very narrow halls, they would stop at various rooms along the way and pick up other members of the community. note: when you are in the hospital and coincidentally know 2 other people on the same floor who also happened to get shot at the same time as you IT IS TIME TO MOVE. and on it went, sloooooow up the front hall, slooooooow up the back hall. back down to the room. repeat. then someone had the bright idea of wedging a couple of kids in a second wheelchair just to make sure that the entourage really took up all available hall space. this literally happened EVERY NIGHT.
now i realize that this sounds judgmental, and i'm certainly not saying that anyone deserves to be shot. but when you still have a house arrest bracelet on your ankle and i watch your 3 different baby mamas rotate shifts, i am inclined to believe that you are living in a gangsta paradise, and may just have played a small part in your fate. and when you refuse to do any of your own cares, snap and clap at the nurses to communicate your needs, and pee/poop the bed out of laziness and entitlement then insist that we clean you up despite the fact that you are perfectly capable of doing these things independently, i am inclined to resent you.
so to recap: we have a productive member of society. kind, polite, participates in own cares and follows medical instruction. then we have a felon. rude. obstinate. unwilling to do even the most basic things despite the fact that he is perfectly capable.
lets take a guess. who walked out (or was wheeled out by an entourage member, most likely) unscathed, and who is facing a very serious diagnosis with a crappy prognosis?
that's right.
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