I have a small problem taking care of quadriplegics. Nurses, I think, enjoy caring for certain types of patients and dread caring for other types. I personally find it of the utmost difficulty to take care of people that cannot move.

Which isn’t to say that I don’t try my best and do a good job. I can attend to the physical aspect perfectly, but I find that I’m completely closed off emotionally. I always try to keep some emotional distance from every patient (although sometimes get sucked in when I least expect it), but with quads I find myself not only keeping distance, but building a big huge wall.

Writing this on a blog makes it sound as though I am an uncaring coldhearted sort of nurse, but I assure you this isn’t the case. Even so, we all have our limitations.

I find it difficult to even look a quad in the eye. I feel as though they are in a place that I can’t even imagine, that I can’t even begin with empathize with. Whenever I look someone who is a quadriplegic in the eye, whatever is staring back at me is simply too much to take on, and so I don’t try. I wouldn’t call myself an overly active person, but I do take time to appreciate every single day that I can move all of my appendages. I’m not out running marathons, but I have a zillion hobbies and would feel lost if cut off from the chance to create things.

If the person has been a quad for quite some time, and they have to be in the hospital for whatever reason (pneumonia, etc), I find it especially difficult to connect with them. For almost every patient I have, I can form some kind of frame of reference of where they’re coming from. I’ve worked in nursing homes; so I can identify a little bit with what a nursing home patient’s life is like. I can certainly identify with your general patient off the street who went to work that day ignoring that nagging feeling in his chest until it became unignorable. Not that I’ve ever had chest pain, but who doesn’t think, even for a split second, that they have a brain tumor when experiencing an especially bad headache? :-) I can certainly identify with patients who have come in after an overdose. Again, not that I’ve been there, but I’ve been in the frame of mind that supports such an action.

But not being able to move yet being fully conscious… that’s too tough. It’s almost as if they’re telling me with their entire being that I will never be able to understand, so don’t bother trying. I guess when I had trouble taking care of patients that were dying, I read tons of books (some good, some not) about death and eventually felt much more comfortable with the situation. Anyone know any good books about what it’s like to be a quadriplegic?

I love this blog. Go Hermes.

Residents are fun to read about. This blog is also quite interesting. Go Mr. Hassle!

I was in charge (again) tonight. The OR called very early in the shift to notify me that they had a patient for us. It happens – sometimes cases go longer than expected, sometimes there are complications… so the patient comes to CCU, usually intubated.

This patient had a huge belly surgery. Usually this means that they have massive fluid shifts. It isn’t at all unusual to pour 5+ liters of fluid into these patients within the first 8 hours. This particular patient arrived at our unit intubated with 2 peripheral (in the arms) IV’s. Usually, if the patient is unstable enough to spend the night in ICU, they come from the OR with an arterial line (aka art line – used to constantly monitor blood pressure and draw labs from) and a central venous line (”CVP” – a line in their neck that facilitates rapid fluid administration and also helps in drawing blood for labwork). Our patient had neither. Since her blood pressure was stable, we figured we wouldn’t press the issue.

We were soon dismayed when our patient’s BP fell to 70. We increased the amount of fluid that we were giving IV and called the surgeon (Who was already on our s*** list for writing out his orders on paper as opposed to typing them into the computer. It takes that much more time to transcribe them and is pointless because he was just being lazy). The patient’s assigned nurse told him that it would be nice if we could have an art line and CVP. The surgeon replied that he wasn’t coming back and that we would have to call anesthesia to come insert the lines.

When we called anesthesia, they informed us that they were about to start another case in the OR and would not be able to leave to come start lines for us. We called the surgeon back; he replied that we were then to call the ICU intensivist to come start lines. We did that; the intensivist told us that this wasn’t his patient and if the surgeon wanted lines in, he’d simply have to come put them in himself. It sounds snotty, but really isn’t… what doctor wants to be at the beck and call of a surgeon who skipped out on his responsibility?

All the while, the patient is very unstable and is by this point requiring the fine services of not one, not two, but three ICU nurses. It seemed as though we were pouring fluid into her to keep her BP up, and it was just as quickly flowing out of the drains she had in her abdomen. (It wasn’t; just seemed like it) Out of the blue, a surgeon and an anesthesiologist walked in and asked if we needed lines. We said we did, and they went to work inserting them. I have no idea why they showed up; as far as we knew, no one was available. I think we just figured that they had some time before the case started. Or maybe Dumbass Surgeon told (begged?) them to go do it.

Unfortunately, inserting lines was not to be an easy task. If they’d done it at the start of her case, it would have been a piece of cake to find veins and arteries to poke. By this point, though, she had a good few liters of fluid under her skin (third-spacing) and it was much more difficult. Apparently they were taking a little too long, because along saunters in the hospital’s medical chief of staff wondering where on earth his anesthesiologist and assistant are. When he finds them diligently working on this woman, he expertly jumps in and has just as much trouble. Not ones to give up easily, they stuck at it until the lines were in. By this time, though, Mr. Chief of Staff was none-to-happy that his case was going to start late and asked who the patient’s surgeon was, and we all happily told him that it was Dr. Dumbass Surgeon.

After things settled down a little, I was telling the nurses on the other side of the unit what had happend. One of them asked if I was going to fill out a QRR (Quality Review Report, aka “writing someone up”). I briefly considered it before realizing that Dr. Dumbass Surgeon single-handedly held up the Chief of Staff’s last case of the day and figured that I wouldn’t need to write a QRR – the matter would probably be taken care of quite quickly without my little piece of paper :-)

My apologies for the melancholy posts as of late, but if you people would just submit something a little more lighthearted every once in awhile…. :-) I guess it can’t always be fun and games. I found this to be kind of sweet, actually.

Jason H, EMT, writes:

As an EMT, there are strict laws that I am bound to abide by, or I risk my license. As a human being, there is a such thing as common sense and compassion. Sometimes, there is a gray area that I’m very afraid to tread in. Often, I err to the side of the law to protect myself. Sometimes, we can use “Jedi Mind Tricks” to suggest things without suggesting them.

We were called to a woman having a heart attack. In emergency mode, I dropped what I was doing (eating dinner) and we rushed to the scene. On the way, I readied the tools of my trade that we use to save lives. I got the IV ready, I got the heart monitor out and prepared so that we could look into her body and see what was happening, I got oxygen masks ready, and made
sure the regulator was attached to the oxygen bottle correctly. I got together my jump bag, which has every tool we could need until we get the patient to the ambulance. In that bag, there are tools that prepare for the best, but expect the worst. I put defibrillator pads in the pocket on the monitor, in case we had to shock her body back to life. I got the drug box out and ready.

When we got to the scene, we rushed in, running around piles of junk, clothes, a house in the woods, obviously owned by people who were living life from paycheck to paycheck. In the back of the house, there was a bedroom with a hospital bed in it, and a young woman, slightly younger than me, gasping for breath. We found that she had cervical cancer, and it was terminal. The pain in her chest was the pain of knowing that she didn’t
have very long to live. Her heart was fine, or as fine as it could be in her condition. I put her on oxygen to ease her breathing, and checked her vital signs while my partner went to talk to her husband. We needed to know some very vital information, mainly checking to find out if she had a DNR order (Do Not Revive). The only way that a person’s wish for “No Heroic Measures” can be legal in our eyes is if the order is by their bedside and they’re wearing a special DNR bracelet. We went back and
talked with her, wanting to find out if she was aware of her condition.

She was, and stated that she was ready for the pain to end. We talked with her some more, holding her hand as she cried with the pain that the horrible disease caused. She didn’t want us to save her. We gently told her that without the order in hand, if we took her to the hospital, we would be required by law to attempt to save her life. Not very many people realize what kind of trauma CPR is to a body. She didn’t want that, she wanted to
be comfortable. We sat there, holding her hand, and prayed with her, offering the only prayer possible, hoping that the end would be as easy and painless as it could be. She had enough pain medication by her bed to end it all at any time. We gave her one pill, waiting until the rest of her family could get there and talk to her. We left, as there was no more that we could do for her. I hugged her husband, as he broke down sobbing while
he signed our paperwork. He thanked us for helping her. I told him that we didn’t do anything other than talk to her. I think that’s all she needed.

As I rode back to our station in the back of the ambulance, I looked around at everything we take with us with the sole purpose of saving lives. I realized that even with the most skilled paramedic and the best tools money could buy, when God calls one of his children home, there’s nothing we can do about it. It’s a very humbling experience.

Jill, RN, writes:

I wrote this the other night, after a very emotional shift. I don’t know if you will find it interesting, but wanted to share it with somebody. Last night I … watched my nursing instructor from 12 years ago die.

I called her sister, I had never met her. “Your sister is doing much worse, you better come to the hospital.”
I met her family for the first time. A nice sister that looked a lot like my teacher did before she got sick.
I asked her brother, a priest, if he wanted me to call a priest for the family. Her sister asked to use the phone, I heard her tell her mother, one of her students is taking care of her, she’s in good hands.

I learned a little about my teacher that I didn’t know before.
I washed my teacher’s body, cleaned the tubes coming out of her abdomen.
I changed the chest tube dressing that had saturated her gown and bed.
I put cream on her breast, the one consumed by cancer.
I put a rosary in her hand, and an angel in the other one.
I told her siblings how much I enjoyed having her as a teacher, she was so wonderful.

I hung drips to try to save her life.
I thought about her standing in front of class, lecturing on the GI system as I assessed her abdomen.
I whispered in her ear that I would take good care of her. Only 52 yrs old, she seemed so old 12 years ago when I was a student of 19.
I watched the ventilator, pumping air into her lungs, struggling to ventilate her.

I covered her eyes with gauze, they wouldn’t stay shut. I couldn’t look at them anymore. Her beautiful blue eyes….so swollen, the swollen sclera oozing out, I couldn’t look at them anymore. Was that wrong? I told her siblings it was to keep them moist and protect them, I couldn’t look at them anymore, she was gone…dead…not yet, the ventilator pumped 12 breaths into her a minute, while she gasped in between. The powerful drugs forced her heart to beat. Pulse 120……slowly, very slowly, too slowly, it stopped beating… not yet. It kept going. What was she waiting for? The end of my shift? I turned on the TV in her room, put the rosary on. I prayed silently with the TV as I charted. Dr. called, notified of decreased blood pressure despite meds. I told him, she’s dying, there’s nothing we can do. Start a neo drip, get her blood pressure up. Is he crazy??? She’s dying. Slowly, I go get the med he ordered. It wouldn’t work, I knew that.

Pulse 48, b/p 60/30. The doctor comes in, “Call the pulmonary doctor.” What? She’s dying, there’s nothing we can do. I call his service, he’ll call back.

The doctor still has not gone in the room. Pulse 20, unable to get blood pressure. Asystole. Doctor, she’s gone, are you going to go talk to the family?

I clock out and go home, I had already said goodbye.

Bye Mrs. L, thank you for choosing me, out of all the students you’ve taught, to die with.

I know it’s been awhile since I’ve posted. Sorry – was back home in the midwest last week.

My hospital has installed a Linear Accelerator. I’m sure it does all sorts of things, because it cost about $1.5million. (I won’t tell you how much the vault it is encased in costs) I also know that what it does has something to do with zapping cancer with the utmost accuracy.

The administrators and radiology departments have been pretty excited about getting this thing. It’s finally finished, and yesterday when I went into work, there was a huge white tent taking up half the doctor’s parking lot. Not connecting the two at the time, I wondered as I walked into work what the white tent could be for.

I needn’t have wondered for long, however. As I approached it, I could see that there was a big banner which said, “The Hospital Welcomes The Linear Accelerator” or something just as goofy. [It got its' own banner!] Later, the operator announced over the intercom that a reception was being held outside under the big white tent to celebrate the Linear Accelerator. [It got its' own reception!] I walked out about an hour later with a coworker and found tables catered with hot hors d’oeuvres and “pretty food.” [It got its' own... well, you get the picture.]

My coworker and I got a plate (A see-through plastic plate with a lovely design etched into it. The nicest plastic plate I have ever seen, in fact.), took some food then sort of stood back and watched. Someone dressed in a nice suit was offering tours of the new Linear Accelerator. I decided to go see what the big hubbaloo was about, so followed the nice lady downstairs to the radiology department. We walked into a big vault (which was disguised as a room; in fact, I did not notice the 6+ inch thick door to the vault on the way in; just on the way out) and we got a little presentation. The machine itself is quite impressive and someone behind me actually called it beautiful. After a few minutes, I decided to return to my unit as I had some medications that were due.

Upon exiting outside to go back to CCU, I heard very lovely music when I passed the white tent. Can anyone guess where that lovely music was coming from?

Why, it was coming from the Linear Accelerator’s very own harpist, of course.

Last night, I was in charge. At one point, I had to move a patient from a private room into a semi-private room to accomodate another patient that was going to be transferred from another floor and would be requiring a lot of equipment. When I went to ask Patient #1 if this would be okay, he was very polite and agreed.

We started filling our beds, though, and when discussing Patient #1 with the nursing supervisor, we decided that we needed to get him out of CCU because after all, he wasn’t on any titratable medications, vitals were stable, and come on – he was sitting up feeding himself dinner and reading the paper. Hello? Why the heck was this person in my unit? He could have been at home for heaven’s sake.

Right as I was about to call the surgeon to ask if I could move this patient, I happened to look up into his room – and found him trying to get out of bed (he was stable, but still hooked up to an IV, EKG leads, a pulse oximeter, a blood pressure cuff, and a teeny bit of oxygen, all of which sort of have their own tubing and wire). I put the phone down and walked into the room to find him tangled up in all these tubes and wires, trying to get out of bed, while his wife sat calmly across from him. Watching. I asked what he was doing and he replied that he just wanted “all these wires” on one side. I explained that that would not be a good idea – we had left the wires how we wanted them; you know – untangled. He then said he just wanted to get up.

Sometimes getting up with all the tubes and wires is possible if, and only if, there is a nurse or aide to deal with the wires – keeping them untangled as the patient moves around. I explained this to the patient, and told him that maybe he should stay in bed for now (since I was intuiting that he wasn’t quite all the way with us mentally anymore). He agreed, and when I got him all settled, he looked at me and said, “Now, I just have 3 questions, and I have to tell you – I think that they are VERY reasonable questions.” I told him to ask away, but instead he kept trying to justify these questions to me, and kept saying how reasonable they were. I kept telling him to go ahead and ask. Finally he took a deep breath and asked me, “Okay. Now exactly how many input and output wires do I have?”

I have never been asked this question.

I explained the tubes and wires and what they were for. He then proceeded to tell me that he was an electrical engineer and that he now needed to know how many milliamps were flowing through these wires? My face must have been plastered with ignorance on this topic, because he then looked at me and said, “Oh, but of course you probably don’t know that answer – but at least tell me, is there a ground for each of them? What kind of relay switch is back there? I’m assuming it can handle about 120 volts, oh…. but maybe not. Gosh, look at those bugs! Aren’t they fascinating? Damn, there sure are a lot of them…”

On and on. I found some tactful way of saying that maybe he could put all of this electricity stuff out of his mind and try to relax, and he looked at me in the most comical way, like a crazy person in a cartoon would, and said, “But … electricity is relaxing!“

Huh. I didn’t know.

I regularly tie people up.

I’m not immensely proud of it (or even a little bit proud of it) but I guess it’s quite necessary.

Imagine that you’re in a deep sleep. You hear noises; your level of conciousness rises a little. More and more you realize that you’re uncomfortable in so many ways. Your back hurts, your limbs feel heavy, your arms are sore, even your nose feels out of whack. Since you’re still only very partially awake, you try to see if you can move somewhat. You can, but feel as though the command that originated in your brain took at least 10 minutes to reach your arm, which is still trying to obey.

Meanwhile, the unfamiliar noises persist. You feel as though you’re stuck in a sci-fi movie. Beeps, blips, talking, scraping, phones ringing… that doesn’t sound like your phone at home. None of these voices are familiar. (And why hasn’t the message from your brain made it to your feet yet?) Your eyelids feel as though they are stuck shut.

Then you realize… you aren’t breathing. How can that be? All of a sudden, your mind is moving faster than it ever has, trying to figure this out. You realize that your throat hurts, it feels full. Your mouth is dry. You aren’t breathing. In the fraction of a second, all of your senses have fully come alive and the commands your brain is sending to your limbs are speeding up. You try to take a breath (God, it’s like breathing through a straw!) but right at that exact moment, a woosh of air is being forced down your throat from this straw. An alarm explodes right by your head and the combination of all that air has irritated your lungs. You start to cough. An even more annoying alarm goes off right by your ear. What the heck is going on? What is this straw that won’t go away? Getitawayrightnow!

So, half asleep, groggy, disoriented, you pull out your endlessly annoying endotracheal tube. The very tube that’s keeping you nice and oxygenated.

That’s why we restrain people. So that when they start reaching for tubes and wires that were very difficult to place, they are unable to remove them, or tug at them. Seems kind of barbaric, huh? But removing tubes almost always necessitates the re-insertion of tubes. If it’s a breathing tube, the interval between removal and reinsertion could be very dangerous for the patient, as they are not being oxygenated well. Pulling out an ET tube that has not been deflated could cause vocal cord damage. At the very least, replacing a nasogastric tube or foley catheter is just downright uncomfortable.

Even if the patient is starting to take breaths on their own, they still may not be well or awake enough to breath completely on their own yet. That annoying nasogastric tube may still be draining gunk from the stomach – without that tube, they may become nauseated and start vomiting. And if you’re in the ICU, chances are very good that you’ve received a foley catheter.

We nurses don’t really like restraining people. For some of us, it’s a visceral reaction – we simply do not like tying people up. For others, it’s a question of paperwork. Restraints require a hefty dose of paperwork. Paperwork that has to be constantly updated, no less. All in all, it’s one of those “necessary evils.” We cannot be at the bedside at all moments, because we usually have another patient to attend to. Sometimes if family is around and they seem trustworthy, I’ll take the restraints off the patient and the family can deal with them trying to pull things out. But I’ve been burned before – sometimes family members get tired of doing that, but neglect to tell the nurse that they’re leaving the room. Henceforth, the patient remains alone and unrestrained, and tubes are inevitably dislodged.

I usually tell families that the patient is sedated (which is usually the case) and is in a state where they don’t know exactly what’s going on. So if they become concious even a little bit of all these tubes, their primal reaction is to remove the source of discomfort. They don’t realize that they are removing life-sustaining tubes; they are just trying to get that thing out of their mouth so that they can go back to sleep. We nurses always try to be at the bedside when a patient is starting to wake up so that we can reassure them, remind them of what’s going on, or give them more juice to return to sleep.

There are all kinds of restraints: wrist and ankle bracelet restraints that we tie to the edge of the bed (prevents the patient from bringing their hands to their mouth, or prevents them from throwing their legs off the bed), vest restraints that prevent them from exiting the bed, or my favorite: mitten restraints. Mittens go over a person’s hands and on the palm side are very very thick. When applied properly, the fingers are unable to grasp anything. Therefore, you can usually remove wrist restraints, leaving the patient to move their arms about as they like. They won’t be able to grasp tubes to pull. However, some patients are definitely able to get out of these.

I’m sure it’s pretty scary to experience what I described in the beginning of this post. I’m sure it’s even scarier to try to reach for the thing that’s causing you discomfort and find that you are unable to move your arms. When a patient is waking up, I always remember to tell them that they are restrained, and that is why they can’t move just yet.

I still feel bad to have to do it. Hopefully there is not a special hell reserved for us.

Well, this is a new one one me. Blogathons! Apparently, you sponser a blogger who you think is supporting a good cause, and they have to blog every half hour for 24 hours.

I love animals. I have 2 cats. I was quite upset to hear about the cat mutilations in Denver. Reading about dogfighting can put me into a bona-fide rage. Anyway, BeerMary is doing the Blogathon this year, and for a good cause.

Click here to read about BeerMary’s cause and consider supporting her!

My last post was about what happens when we withdraw treatment from patients. This post will be about not withdrawing treatment.

There have been many medical advances which have allowed us to learn to get patients through the very serious part of some illnesses with their lives. Sometimes a pneumonia just gets ahead of someone quickly and the “bugs” enter their bloodstream and they go “septic.” The patient was active before the illness, and there’s a good chance they’ll be active after the illness, provided we can successfully treat them and the sequelae.

But some patients are wallowing in nursing homes, not being very active or even very verbal. Yet their friend pneumonia shows up to take them peacefully to the other side, and we wrench them violently back with vasopressors, postive pressure ventilation masks, ventilators, antibiotics. Then if that treatment is only partially successful and the patient has not made a full recovery, we flog them some more with permanent feeding tubes and/or tracheostomies.

We recently had 2 patients who were completely ridiculous ICU admissions. I’m not saying they were riduculous hospital admissions, just Intensive Care Unit ones. One was a 90+ year old woman who was intubated and put on a ventilator. An artery feeding the lower half of her body partially clotted off and left her legs bluish and very painful. No surgeon would take her to surgery to fix it – she was an AWFUL surgical candidate. She could not eat, so we fed her intravenously. As if this weren’t bad enough, she was a full code for about a week there – if her heart had stopped, we would have had to do compressions and defibrillation.

Every doctor possible was eventually consulted for her case. The family wanted EVERYTHING done, even dialysis. In my very soul, I felt as though we were criminally assaulting this woman. We never did get to dialysis, and we finally made her a “no code.” She passed away a couple of weeks after her admission surrounded by a family with questionable motives and in horrible pain. What this woman needed from the get-go was a morphine drip and some peace.

The other admission made me so angry. It was an 80+ year old man with severe dementia who was admitted with pneumonia. Although he was designated a “no code/active care,” he still bought a bed in ICU. Active care means antibiotics, IV fluids, supplemental oxygen. The “no code” part means that if his heart had stopped or if he stopped breathing, we would have done nothing to resuscitate him. Antibiotics, IV fluids, and oxygen are things that a general medical floor can handle with ease. Instead, he took up a bed in my exceptionally busy ICU.

I don’t mean to sound callous, like he was wasting our time… He was certainly an appropriate hospital admission, but not an ICU admission! And even though he was a no code, when he started to decompensate, his nurse still considered doing more and more to “save” him! I understand that death of a loved one is painful for the people left behind, but can someone please tell me the point of trying to save someone severly demented, unable to care for themselves? I can say with 100% certainty that not only would I choose to just make my own mother comfortable in that case, I would be horrified to have her flogged in an ICU with uncomfortable oxygen masks and restraints.

Some people never even really recover from pneumonia, even if they were playing 18 holes twice a week. I’m not sure if the general public thinks we can cure everything these days or what. The human body MUST be able to heal itself somewhat. Nothing we do ever actually helps the body heal – the interventions we provide merely get the human body through the storm. “Supportive care,” it’s called. Sometimes it works, sometimes it doesn’t. I’ve even seen people younger than 40 succumb to exceptionally bad pneumonia despite every single high-tech intervention imaginable. Of course I guess I could say that antibiotics help heal the body, but multiple antibiotics can also cause antibiotic resistance, superimposed infections (fungal infections that crop up because we’ve killed off the “good” bacteria as well as the bad) and contributes to drug reactions/interactions.

I know I’ve ranted about this sort of thing before, but it’s my pet cause. It breaks my heart to have to do the things I have to do to people I know won’t get better. Don’t think for a second that I don’t follow orders I consider to be excessive – my job is to do that regardless of my personal beliefs. But it is also my job to educate people about the limitations of what we can do. Sometimes it’s hard for the family to step back from the situation. It becomes a mentality of “beat this at all costs,” like it’s some sort of challenge that must be won. That’s understandable in some cases.

Recently, we had a 60ish year old patient who we were trying really hard to save – we used every treatment we could possibly come up with. Unfortunately, he had a major setback and we started to address code status with the family. They maintained that they still wanted everything done, despite our predictions that he would code very soon. We thoroughly explained every possible code intervention – compressions to defibrillation, and the family wanted it all. When it was looking like he would code within an hour or two, his nurse brought the crash cart into the room, put the patient onto the backboard for CPR, stuck the defib patches to the patient and hooked them up to the powered-up defibrillator. In addition to the ventilator and the continuous dialysis machine, the defibrillator was beeping with every heartbeat.

Although we had already explained each of these procedures in detail, the family was horrified to actually see the equipment fired up and ready to go. The nurse explained what everything was for, and what it would do, and the family immediately said that we would be doing none of it. We removed the crash cart from the room, but continued with the ventilator and dialysis machines. About an hour later, the patient’s heart rate slowed and then stopped. The family was all there and although it wasn’t the most peaceful death with the machines still around, it was better than having an electric shock and someone pounding on his chest.

The nurse made the right call with that particular family. He’d already had a good relationship with them and it’s a 100% certainty that the patient would NOT have survived. I can’t help but to think that we somehow imposed our beliefs… but we also advocated for the patient…. for his right to have the best death possible. It’s a pretty difficult position to be in.