patient advocacy, yet another joy of nursing.

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.

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.

you have GOT to be kidding me.

Yesterday I got a very special patient out of the ICU. I don't mean special as in needs, or a crazy diagnosis. This guy is the stuff that stories are made of. I'm pretty sure that I will never [be able to] forget him, and here's why.

I was getting an ICU transfer and frankly I thought I was pretty lucky. He just had his gallbladder removed, was pretty stable, and just got admitted to the ICU overnight to monitor a preexisting heart condition. This guy is in his late 20s, walking, talking, and sounded like an easy patient. INCORRECT.

The guy rolls in and the first thing he does is strip completely naked in his bed because "I like to sleep naked". Sidenote: this is fine AT HOME IN YOUR OWN BED. Please do not make me see these things. Yes, I am a nurse, but that doesn't mean that I want to see 300+ pounds of what your mama gave you hanging out for 10 hours in a row. Ok. So the naked man now begins to give me orders because "I'm kind of OCD". Whatever. I spent the next half hour feng shui-ing his room and fetching a fan to aim at the wall because "I need circulating air", water, blankets, suction for when "I need to cough and there's this hunk of phlegm way back there and I need to suck it out", pillows, special pillowcases to wrap his legs in because the SCDs make his legs sweat...and so on. At this point I still thought maybe the evening could be redeemed. Maybe once I got him settled he would just leave me alone.

HA.

It is now 1600. At 1615 I go eat my lunch. If I don't go eat my lunch at 1615, I do not have time to eat and that makes me very sad. Needy needy man, of course, chooses now to request his bed bath. First of all, he already got a bath, and I know it. So I hinted around that he already got washed up in the morning, to which he replied "at home I take like 4 showers a day. I like to be clean". Can we say overkill? I could maaaaaaybe understand 2 showers a day, but 4? That's not cleanliness, that's mental illness. Fortunately for me, at 1600 we had no linens on the floor, and I got to postpone bath time until after lunch. So at 1700 I headed in with my big stack of towels and got to work.

Forgive me if I'm wrong. Normal people do not feel comfortable being completely naked and taking a bath in front of their parents and brother. Well, this patient thinks that's A-ok. He spent a good ten minutes lovingly scrubbing his special place while his entire family sat in the room. For the record: NOT OK. This led to a lively discussion about mom, who had back surgery and wasn't allowed to bathe at all for awhile. "Not even your cooter?" asks special patient. No, not even there. This conversation? Also NOT OK.

So I make the guy wash everything he can reach and I helped him with his legs and back. Then, to my horror, he whips out a tube of hydrocortisone cream and proceeds to tell me about his rash. Apparently the hospital soaps don't work well with his delicate skin. He then begins lovingly rubbing cream on his special place. Yes, his family got to see this delight as well. Oh but the fun doesn't stop there. He goes into excruciating detail about the rash on his butt, and asks me to "just lube up a finger and run it all up the crack really good".

Sidenote: this is my life. If I had a dollar for every time a freaky patient with no boundaries asked me to do something repulsive, I could leave this job like 10 times over.

So bath time is done, thank God. But not to worry! The fun is far from over. Unfortunately, this guy had a catheter in that had started to leak. The day nurse took it out, and every hour for the next 6 hours I got to go in and empty a tiny bit of urine from the urinal. This led to a lengthy discussion about diuretics and my patient's peeing habits. For the record, I do not enjoy hearing about your pee unless I ask you. Otherwise you can just keep that to yourself. Thanks. We also had another issue as my patient informed me that he "dribbles". This means that every time I emptied his urinal, I also had to bring him more linens for his "accidents". I'm sorry. 29 years old and haven't quite mastered the art of peeing yet? This may be a life skill that you should be working on.

And this all went on until 2300. Like clockwork, the call light would go off every 20 minutes and I would go down to his room and be presented with a list of four to five items that I would haul back to his room. Once I got down there, he would remember several other "favors" to ask me. It got to the point where I was praying to be fired or just drop dead...ANYTHING to not have to deal with this patient another second.

To clarify, I don't have a problem helping people, that's my job. I do however have a problem with excessive neediness. Group your requests together so I'm not doing laps up and down the halls. If you can do something for yourself, then JUST DO IT. Don't make me do it, don't make me watch you, I am NOT going home with you so if you can't wipe your own butt we need to figure that out before you go. And for the love of all that is good, HAVE SOME MODESTY. It will not kill you to wear a gown, so leave yours on, please.

So today I go back for more. Maybe he'll get discharged? Oh please oh please oh please.

have i mentioned lately that i love my job?

septic medicine patient from africa? she might have tuberculosis. and considering the fact that i spent about 20 hours with her without a mask, if she has it i've been exposed.

when i go to the doctor there's a question that asks if you've been exposed to any hazardous materials. i usually say yes and write "patients" by way of explanation. this is why.

so now we wait for the results of the bronchoscopy.

eventful PM

when i write notes and have nothing to say, i usually start with "uneventful PM shift". tonight did not apply. a rundown of my special friends

1. a spanish speaking only man who got drunk and fell down. apparently sometime during the festivities, he knocked a tooth loose. i came into his room to answer a call light. he says "mi diente" and hands me his left front tooth. i tell trauma, who go put the tooth back in the socket and make a gauze dressing. when i checked on the patient 15 minutes later, the tooth was on his bedside table. he had taken it out to eat a chocolate chip cookie. needless to say, the tooth will not be getting replaced. when i tried to explain this to the patient in my minimal spanish, he was very understanding. he plans to "just get dentures".

2. a twentysomething in a car accident...not much excitement there.

3. a septic medicine patient from africa who speaks only a rare dialect that we don't have an interpreter for. temp of 103.2. heart rate 127. shaking chills. can't seem to find a source of infection. i have been watching too much House, and therefore am somewhat convinced that she has Dengue fever and so do i. but not to worry!! per the progress note "risk of morbidity: medium". lets all breathe a sigh of relief for that one.

4. and finally, a man who got his arm stuck in a grinding machine. surprise surprise, he too is a spanish speaker!! (in case anyone is keeping track, i'm at a 75% language barrier here). but as it is not enough to simply get your arm almost ripped off, he now is in uncontrolled A-fib. hopefully he doesn't need a doctor for any reason, because he's lucky enough to be a plastics patient, which means that his doctor will not call back, even after you page him 3 times to ask a question.

then on the way out of work, we had to walk through an arrest. security and the police were gathered in the middle of the hall handcuffing and frisking a man. nobody batted and eye and we walked on through. just another day on the trauma floor :)

pain control

pain is the sixth vital sign, or so everyone has been trained. working on a trauma floor, EVERYBODY is in pain. the narcotics are due every 1-2 hours and the reassessments of pain levels never end. most often, people are under the impression that hospitalization is supposed to be painless...right. for the record: when you are shot or stabbed or fall out of your tree stand or get hit by the city bus, you're going to have pain. my job is to give you your medicine, make the doctors order you more if it's genuinely not working, and be sympathetic. most often this involves offering to make you a heating pad. while i realize that this probably won't do much for your 4 broken ribs, it's the thought that counts. every staff meeting on the floor begins with a little blurb about how we're supposed to be doing our pain assessments, and how we score low on controlling our patient's pain. as most people would like to be medicated until they stop breathing, i honestly don't take all that too terribly seriously. bottom line: i can tell when people are truly in pain, i bring them medication as often as i can as long as it won't hurt them, and then i push tylenol and ice packs and deep breathing like it's going out of style. most of the time, this works fairly well. this week? not so much.

it always starts with an admission that i think is going to be easy. this time it was 'just abdominal pain'. unfortunately what i thought was a tummy ache turned into bounce back admission with a history of heroin and crack use and no IV access. so i picked this patient up as we were waiting for a PICC line so i could give her fluids and IV pain meds. unfortunately in the meantime, percocet wasn't working to control her pain. i'm not surprised, as NOTHING WORKS FOR PAIN AS WELL AS CRACK. i genuinely felt bad for this lady, though. she was writhing in pain and we just couldn't get the line in. each time the IV nurse repositioned the PICC, it was in the wrong place. the hours went by, the line got repositioned 4 times, and the patient still had no access for IV medications. this is where i got creative. and i'll admit, i was pretty proud of myself for being innovative. if i couldn't give the meds IV, i could give them another way!! intermuscular medication was the solution!! i could give her a little shot of fentanyl and then she would know that i was serious about controlling her pain and maybe it would even help a little. so i called up the pharmacist who told me to go ahead, and gave my lady 50 mcg of fentanyl in her bicep. then i gave myself a little pat on the back for coming up with a solution.

45 minutes later, i was in the room with the patient and a med student. the student was doing her assessment, and i couldn't help but notice that my patient was getting pretty sleepy. as she started to slur her words, i got a little concerned. the med student was kind of weirded out too, so i grabbed a set of vital signs. i was in the middle of telling the student that i was pretty sure she was fine as her oxygen levels, pulse, and respirations were all normal, when the BP recorded. 80s/60s. in a patient with previously high blood pressure. at this point, the patient was only waking up to sternal rubbing. i called the medicine resident, who said that he'd be down in 5 minutes. i called the Stat RN, grabbed some oxygen just in case, and went to get a vial of narcan.

in my head i knew that this had to all be because of the medication i had given her, but the whole situation didn't make much sense. first of all, 50 mcg of fentanyl shouldn't have had that much of an effect on someone who uses hard drugs. secondly, the intermuscular route usually isn't absorbed that fast, and i mean really, blood pressure of 80s/60s just because of narcotics? the whole thing seemed wrong. so i was running around the room getting things set up, and the commotion attracted the attention of the on call trauma resident. this guy just happened to be specializing in emergency medicine and i could tell from the gleam in his eye that he really wanted in on the action. he stood in the hallway for a few minutes watching, and then stopped trying to fight the urge to participate and came in the room. he started checking reflexes, and sternal rubbing the patient, then checked her pupils. tiny, of course, as is common when someone has gotten too much narcotic. he suggested that i "give the narcan before she codes". we gave the narcan. it took a looooong time for her to wake up, which is weird as the drug usually reverses narcotics pretty quickly. the medicine resident arrived, i bolused her with a couple liters of fluids, and her blood pressure came up. she was still really sleepy though, which made me nervous. naturally, i felt awful. even though i knew i hadn't done anything wrong by giving her the fentanyl, i felt like i caused all this drama. so as i usually do when i don't feel right about something, i held a little vigil. i ran around to all my other patients, and in between grabbing meds and changing dressings, i would pop in her room to count her respirations and take a blood pressure. when it came time to do report sheets, i sat in her room to write them. my computer charting got finished from the chair that i pulled up to her bedside. her blood pressure was stable, she was still really sleepy, but everything else was ok, so i felt a little better. when she woke up to me yelling her name or shaking her arm, the patient said she had no pain. well, at least i accomplished something.

it was finally time to punch out and go home, and i should have left well enough alone. but nooooo, i had to get just one more blood pressure so i could sleep that night. i snuck into her room, blew the cuff up, and wasn't too terribly surprised when the result came back at 70s/50s. and so we started the whole process over again: bolus, Stat RN, medicine resident, narcan...deja vu. then i pushed her upstairs to the medical ICU for a possible narcan drip. then i punched out, an hour and a half after my shift ended. i checked up on her the next day: completely fine. awake. stable BP. go figure.

pain control is officially dead to me.

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.