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Sittin’

What do you suppose the hardest job in a hospital is? Being an oncology nurse, cleaning up bedpans, charge nurse of a busy floor, surgeon on-call during a busy night… there are quite a few difficult jobs to be done in a hospital. It is of my opinion that one of the hardest and most frustrating jobs is that of a … sitter.

Yes, you read me right. Sitter. A sitter is a person who must sit with a confused patient and make sure that they do not get out of bed or pull on their PEG tube, foley, tracheostomy, oxygen, gown, SCD’s, colostomy pouch, chest tube, etc, etc, etc. I realize that it may not be a very “difficult” job, but it sort of is. You have to constantly keep your eye on the patient, and constantly redirect their hands. Patients can get a little testy when you keep telling them they can’t pull out their foley catheter, when in fact, there’s nothing else they’d rather be doing at that point.

A recent patient of mine, “George,” was a patient who was made for the sitting profession. He hadn’t slept all night and had lots of nice tubes and wires to pull on. George demanded attention. Even though I only had two patients, and George wasn’t one that you could consider “unstable,” I easily spent 90% of my time dealing with him. We were on the overflow unit, where resources are usually non-existant. There were 2 nurses for 4 patients. One patient’s family was in our faces every other minute or so. Another patient was on the call light every 5. One patient was admittedly very quiet, but still quite ill, and then there was George. It was only us 2 nurses left to deal with the melee of the telephone, doctors, call lights, meds to be given, lab tests to be called…

Every single time I walked by George’s room, I was greeted to naked George, because he refused to leave his gown on. Now, I could care less about naked George… but room 36′s 87-year-old wife who just happens to be walking by might not be as apathetic. In the space of 4 hours, I replaced George’s oxygen mask, his gown, his SCD’s a zillion times. I successfully thwarted his attempts to pull out his chest tube and central line. I found that I was unable to prevent him from tugging his urostomy bag off when I noticed a huge wet stain on the gown that I had just put on 3.5 minutes prior. You can’t just tape a urostomy bag back in place… it won’t work. Oh, did I remember to mention that George was on isolation??? So every time I was to go into his room, I had to don a mask, gloves, and gown. Guess how many times I actually had a chance to put all that crap on?

So although George was stable enough to be transferred to the medical floor, I found that I was spending the greatest amount of time with him. I would like to point out that George was old, and although quite alert, was a bit forgetful. He would certainly stop throwing his legs over the side of the bed when I’d ask him to stop, but he’d just start again 2 minutes later. I realized that the only safe thing to do would be to ask the doctor for a sitter.

We don’t get sitters in ICU. We nurses are the sitters. One could argue that we shouldn’t need them… we “only” have 2 patients (but, ya know… they’re in ICU for a reason), and the rooms have glass doors. The patients are easily visible from the nurse’s station, unlike on the general floors, where the patients are down the hall, out of sight. Since George was transferring to the medical floor, I believed a sitter would go a LONG way towards retaining his future nurse’s sanity. I easily got the order from the doctor, but wouldn’t you know… the staffing office would have to actually procure a human being to act as sitter, and that would take a few hours, so… sit tight there with George for a little while, won’t you?

You might be asking why I didn’t just restrain George. I hate restraints.

That’s where sitters come in. They literally stay at the patient’s side and gently re-guide the patient’s hands. They put the patient’s legs back in the bed. In George’s case, I think he just wanted attention. When I’d be in the room fixing whatever mess he’d just created, he’d stop. Unfortunately I could not be in the room 100% of the time. But a sitter can. We finally got one for him, and he was transferred to the medical floor.

About an hour later, I took George’s lunch tray up to the floor because it had been delivered to us by mistake. When I walked into the room, I noticed George sitting very quietly and still on his bed. The sitter was changing the channels on the TV. George’s hands were in plain view and he was behaving quite nicely. As I set the tray down, the sitter asked me, “So… I didn’t really get a good report on this patient. Why does he need a sitter?” I couldn’t blame him for asking – George was the model patient at that point. As I described all of his earlier escapades, George just smiled and nodded his head.

Sigh.

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Don’t Poke The Tumor

(Oh my gosh! Two posts in one day!)

Stacey writes:

My husband took me to the emergency room two months ago today, at about 4:30 am. I was having nasty abdominal pain and couldn’t walk well on my own because of it. No nausea or fever, just pain, and lots of it.
The admissions nurse asked me on a scale of 1 to 10, how badly did it hurt? I remember giving her a funny look, because honestly I had no idea how to answer that. But I gave it a shot, and said maybe 6 or 7.

Fast-forward 14 hours later. [Ed: !!!!!]I’m still in ER, and my second doctor comes in. Neither I nor my husband have gotten any sleep in well over 24 hours now. The doctor sits down and introduces himself, says he and my first doctor have been looking over the CT and MRI scans for the last 20 minutes. So, I ask, what’s going on?

Well, I had a liver riddled with tumors. That’s what was going on.

I’m 25 years old. I just got married 8 months ago. All my brilliant mind could think to come up with was, “What?”
Immediately after this, I was admitted into the hospital proper and given my very own room and some much-needed food. My husband settled in the chair by the bed. I sent him home- he needed real sleep too, not a nap in an uncomfortable chair. Myself, I passed out after eating. Tumors be damned, I was tired.

I was awakened at 4:00 am with a request for blood. Ah, the hospital- the only place where they demand body fluids before God himself is awake…
Around 11:00 am we got the news- BENIGN!
I was transferred to a huge teaching hospital that afternoon. The largest tumor was located in a place the doctors here dared not go. I was sent to one of the United States’ leading liver transplant surgeons. If he couldn’t do it, no one could, it seemed.

They had to transfer me by ambulance, I guess it was hospital policy. The EMT’s showed up around 3:45, gurney and all. I told them I could walk. One said I’d be more comfortable on the gurney. Funny, he was right, hehe.
As they strapped me in, one asked why I was in the hospital. Hey, I’m young, in damned good shape, and I looked perfectly healthy aside from the hospital gown, so I didn’t mind his curiosity.

“Liver tumors.”

I didn’t mean to be blunt or anything, but the look on his face really was priceless. I immediately said hey, they’re benign, s’ok buddy, but the damage was done…
I should have read deeper into his expression, it would have told me what was coming.

I got to the big hospital 4 hours later, give or take. You know, when you’re in pain, the worst way to travel is ambulance, I swear. All that bouncing and jouncing did me no good. I really feel for people in those things more than ever after that ride.
So, we got there, I checked in, I got my room, and my first doctor came in. He wanted to poke at my belly. I wondered loudly if that was such a good idea, considering the TUMOR and all. He tried again, and I pushed his hands away. I said it wasn’t necessary to poke at the tumor. Thankfully, I think he saw my reasoning.

From that experience, my husband (who showed up shortly after I got there) and I created the Room Rules.

Rule 1: Don’t poke the tumor.
Rule 2: See Rule 1.
Rule 3: Donations gladly accepted.

I would have paid good money to see these printed on a vinyl banner hung from the ceiling. As it was, we made do writing them on a small dry-erase board on the wall.
Anyhow, by this point it was getting late, and my husband had to leave for the night. He headed to his hotel, and I laid down, turned on the TV, and cried. Yeah, I sound all brave in this story, but I would immediately revert to a bawling baby when I was all alone.
The next day was a bit of a blur. Tests, paperwork, family phone calls, visitors, tests, tests, tests. I was tired. I hadn’t had a good night’s sleep in a few days, and was living off hospital food. I was cranky and wished this all over with so I could go home.

I kind of wish I didn’t make that wish, but whatever. Too late now.
The day after was uneventful until 7 pm. That was when I was notified that my surgery was scheduled a scant 12 hours from then. More paperwork to sign, a living will to fill out, complications to learn about, and my first-ever experience with a panic attack. The lead surgeon asked me to quit smoking. I told him that after all he’s had to tell me, whoever takes my nicotine away is getting a boot in the jaw. I can quit when my life isn’t immediately threatened, thanks. (Yes, I know how bad smoking is for me- that’s not a newsflash. I am in the process of slowly quitting right now. I will be a non-smoker by September.)
After I had calmed down (and had a cigarette) it was nearly 11 pm. My husband, and my brother who had just made it there, went to their hotels. I flipped on the tube and cried again. I was exhausted and didn’t want to sleep. Sleep only makes the inevitable come faster. I would get plenty of sleep later anyway, I reckoned.

I called the hospital chaplain at about 2 am. I was lonely and very scared, and had no one to talk to or sit with me. Maybe it was a bad thing to do, but she didn’t seem to mind. I’m not religious at all actually, but she was fine with that too. She sat and chatted with me until I drifted off to sleep about an hour later.
At 6:30 am they came to get me. My brother made it there to see me off, and for that I am forever grateful. As we hugged I began to cry a little. Then I was whisked out into the cold hallway and down to the elevators, naked except for the thin hospital gown. I caught a glimpse of a beautiful sunrise through the windows in the hall, and I remember thinking to myself, what if this is the last one I see?

I’m assuming the room they took me to then was pre-op. This was the most terrifying 5 minutes of my life. Cold, nearly naked, and hungry, I listened as the anesthesiologist told me what he was doing. This is going to make you a little tired, this is your epidural here, now I’m going to have you roll over, good, good, now count to 5.

1… 2… …………………………..

I woke up in the ICU in such excruciating pain I couldn’t even think. I knew I was in the hospital for something. There was something in my mouth and throat and something making my neck itch like crazy. The room was very dark and long like a dim hallway. Someone was holding my hand, but I couldn’t see who it was. Someone else ran out of the room. I passed out.
I woke up again and stayed awake a little longer. I found a button and pushed it, I didn’t know what it was for but my hands were kind of going on autopilot. My legs were moving a lot and I couldn’t stop them. My neck itched. Someone came in and told me not to scratch my neck, I could really hurt myself. I tried to stop but it itched so badly. Everything hurt, everything from my neck to my knees was screaming, but I was obsessed with the itchiness. At some point I passed out again.

I remember being extubated, but I don’t know when that happened. I didn’t hurt like I thought it would, but then again, I was full of morphine. I remember when they pulled out the tube in my neck, and that hurt like hell. The rest of my memories of ICU are like little flashes of light through a thick fog- my husband leaning over me, my brother asking me how I’m feeling, groaning a lot, wanting to ask what’s going on but can’t because I can’t remember how to talk.
Not being able to talk was really hard. For about 24 hours I was in so much pain and so full of drugs, I couldn’t give my name or tell them where I was. I knew where I was, I knew my name, I just couldn’t say it. You know what it’s like to have something right on the tip of your tongue? It’s like that, only a hundred times more frustrating.

To me, it seems like I was in ICU for about a week. My husband insists it was only a day. Well, time flies when you’re having fun, and crawls when you’re not.
I can’t describe the pain correctly no matter how I try. I was like someone reached inside my belly with an egg-beater and just went nuts with it. Everything stung, throbbed, and burned, all at once. No amount of drugs made it better, nothing made it ease off in the least. Sedation was a blessing.
And that 1-10 pain scale? Nothing rates above a 5 compared to this pain. Natural childbirth might hit 6, maybe. That pain scale is worthless.
When I was moved to my own room, my mother had just arrived from New York. She brought me a little pink stuffed elephant, which has stayed with me to this day, two months later. I named him “Courage.”

Courage the Fluffy Pink Elephant held my PCA pump button for me. I was so out of it I would easily lose the button in the bedclothes or onto the floor, so my mom helped me clip it to the the elephant so I’d never lose it. Courage held my liquid courage supply, haha!
The rest of my hospital stay is very jumbled in my mind. Time doesn’t work like normal when you’re in a lot of pain and on a lot of narcotics. I remember hanging out outside the hospital’s front doors with other smokers, listening to surgery stories and our PCA pumps beeping. I remember fighting to stand up on my own the first time, so frustrated that my body was so weak. I remember one doctor telling me not to smoke, when he reeked of it himself. I had nightmares a lot.

There are two things I remember most though. One, is that no matter how badly off you are, there’s always someone worse. Being in a hospital reminds you constantly of that fact. I simply could not have self-pity after meeting some of the patients there.
The other is that nurses are goddesses. They come when you call them because they know you need them, and they explain what exactly all those pills are for. They listen when you need someone, and they comfort you when you cry. They scare big bugs out of the room so you can sleep. They do a million things you never see, but they still have time for you.
I was discharged 9 days after the operation, and I was so scared I wouldn’t be able to take care of myself. I had a fistful of scripts to take to the pharmacy, but I could barely walk.

The first few weeks at home were really hard. I couldn’t lay down flat, and didn’t own an adjustable bed or a recliner. I slept sitting up on the futon with a bunch of pillows around me to keep me from falling over. I had a pillow across my belly at all times, in case one of my cats jumped on me. I couldn’t eat more than a cup of food at a time, and couldn’t sleep more than 2 hours without having to take a pain pill. It was hell.
Now, it’s been 2 months. The staples are out, the scar is fading into the pink range, and I only hobble a bit now. I’m still pretty sore and stiff, but I can lay down an sleep on the bed. I can even roll over on my own.

I look forward to working again. I’m almost ready to get out on my own again, and I can’t wait! I’ve lost so much time… I want to catch up, you know?

Next year I start nursing school. Wish me luck, OK?

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Grand Rounds

Grand Rounds is up at Blogborygmi! Thanks to Nick for this awesome idea. I’m not all that familiar with the Carnival of the Vanities, but I think this is a great idea for medical bloggers.

Yours truly has taken a few weeks off from blogging, so I was not able to
get an entry in in time. Maybe next time :-)

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Faking It

In response to “John’s” comment to my last post, Azygos wrote a long ditty that he wanted to get my approval on before posting in the comments. I decided that it was so good that I’d just post it here on the main page.

First of all, John’s comment:

Do you guys just assume patients are faking things or is their some criteria for it? I ask this because about 25 years ago when I was early 20s, after having chest pains that took my breathe away for a day and a half I finally went to the ER….

First they assumed it was gastro related and gave me some kind of drink, didn’t help and I actually think it made them mad at me when I said it didn’t help…They were very hesitant to check out my heart because of my young age, thin build, in good shape, etc…

The nurse was standing at the door to my room when another nurse asked her “what they had going on in that room.” I was looking directly at the nurse when she using her index finger tapped herself on the side of her forehead, indicating I was a crazy person…

I got so pissed that I signed myself out of ER and next day went to my PCP who sent me to a cardiologist and within a week I had heart surgery…

I held no grudges but I have never forgotten the incident either..

Is everyone assumed faking until PROVEN otherwise?

And here is Azygos’ reply:

John,

How awful for you to have had to experience such treatment. As a person who has worked ER as a Nurse and as a Nurse Practitioner for 14 years I can tell you that had it been my ER, you would not have been treated as such. I have cared for patients as young as eight who were first diagnosed with a heart problem by me in the ER. Chest pain should always be thought of as real until proven otherwise.

Sometimes nurses get crass and rude the longer they work in the ER. It’s fine to go into the closet and point at your head and twirl your finger thinking a patient is faking it or crazy. It’s just plain wrong to do it where the patient can see you.

In the ER we get an overabundance of patients saying they are having chest pain. Each should be evaluated on an individual basis and a root cause looked for. Often patients of all ages present with stress induced or anxiety induced chest pain. You can still be crazy and have pain. The art is in delineating between anxiety induced pain and actual physically damaging pain (heart attack). We have extremely sensitive tests now which can tell if heart muscle is being damaged, but we don’t have tests other than cardiac cath to tell if a heart is about to be damaged. We have to fall back to our judgment for such things. Twelve lead EKGs, while helpful, are only a snapshot in time and are only good for that moment. One cardiologist I trained with put it this way, it’s a ten dollar test and gives you ten dollars worth of information.

Chest pain is radically different from seizures. People rarely die from seizures, but often die from chest pain. Evaluating a seizure to determine if it being faked or not is an art all to itself. I had a 400 plus pound patient faking being unconscious. She was mad at her husband and wanted to make him feel sorry for her after they had just had an argument. I can’t tell you exactly how I knew she was faking it but I knew she was. I asked her several times to slide over to the ER bed. Frustrated I finally said, You’re too fat for us to lift, you’re going to have to move over by yourself. Hearing this she sat bolt upright and started yelling at me. I calmly replied, now that we have established you are awake will you please move to the ER bed.

It’s being able to take in the patient as a whole when one is trying to discern if a seizure is fake or not. Did the person urinate or have a bowel movement? People who are faking it usually don’t want to pee or poop on themselves to fake a medical condition. Is the person speaking and looking around and following the conversation while having the seizure? Are the person’s eyes tracking the sounds of the emergency personnel? Does the patient’s Spo2 (Oxygen) drop while having the seizure? Does it look like a seizure? I had one teenage boy try to punch me in the mouth while claiming to be having a seizure (it did not work out well for him).

So in answer to your question- NO, we don’t assume someone is faking it when dealing with seizures, but we do take other conditions more seriously as the outcome from a misdiagnosed seizure is almost never fatal, but a missed heart attack certainly could be.

(Hi, it’s me again): I would also like to add that you were very lucky… Leaving the ER wasn’t the best move on your part, as you were leaving the very place that could have saved your life had you experienced complications. I realize that it can be very disheartening and hurtful to have seen the nurse do this, but it’s one nurse. They can’t have all been like that. I hope so, anyway. Oh, and I think I know of a couple of people that would disagree about the EKG only being a 10 dollar test…

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Tricks of the Trade

Pursuant to Defective Yeti‘s call for tricks for his “Tricks of the Trade” article, I thought it would be interesting if nurses and other health professionals submitted their own tricks. I know some nursing students and new grads read this blog, so it would be nice if some more seasoned nurses would share shortcuts, etc.

Just to give you an idea, DY’s tip from a nurse was “Patients will occasionally pretend to be unconscious. A surefire way to find them out is to pick up their hand, hold it above their face, and let go. If they smack themselves, they

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On The Lighter Side…

Jean, an Emergency Department tech, writes:

On the lighter side: A 19 year old kid came into the ER with his approximately 16-year-old younger brother. He said the 2″ cut across his cheek happened while playing football.

Come to find out they were playing “Dave Madden Football” on the Playstation and he had been winning when the little brother whacked him in the face with the remote control…

Ha!

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Comfort Always

I thought this was a nice entry. It’s about the conversations we have with patients when it’s time to cease treating a disease.

http://www.intueri.org/index.php?p=1101

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Body Art

Veronica writes:

My story isn’t just a story, but a request for suggestions from the medical community.

I have a handful of piercings and tattoos: my navel and earlobs are pierced and I have a surface piercing on my left arm, as well as a tattoo on my lower left abdomen. I also play host to uncountable scars from my days as a cutter, scars that resurge when my depression overrides my meds.

I personally have not had much trouble with people and my scars/modifications. When I went to a dermatologist after a cutting binge, they did the whole “Are you a danger to yourself or others,” speech and I got to tell them that I was fine, but beyond that everyone has been great.

My fellow modified people, though, have had incredible difficulty receiving not only adequate but also professional medical care because of their piercings. One young man on a piercing site, BMEzine, writes of the time he was brought to the hospital after a car accident that killed his girlfriend and left him a paraplegic. He had a genital piercing when he came in. As a result, he could often, during his extended hospital stay, hear the doctors and nurses mocking him for it. Others have been forcibly admitted to psych wards because the on-call physician couldn’t believe that someone who wanted to modify his body was mentally sound. Yet another was flat out told that she deserved the infection she got (unrelated, as it turns out, to the piercing) because she had her nipples pierced. I fear that these stories are the norm and not the exception among the community.

Body modification can be dangerous. You poke holes in yourself, you risk infection. However, many young people have been dissuaded from seeking appropriate medical care because of the judgment that their providers pass on them. I do understand the need to assess whether your patient is of sound mind when performing these modifications…a tough call to make when someone desires castration, for example. On the other hand, it is no longer prudent to assume that someone who walks in looking like he or she was attacked by a box of needles is a drug-addict carrying every blood-borne pathogen on the planet. There are people who are otherwise totally mentally healthy, without delusions or pathology, who enjoy body modifications that are non-socially acceptable.

My question, which I direct to all medical personnel, regards how we can obtain better health care from you. To what, if any, treatment are we entitled? Should snide comments be expected if we have pierced unusual areas, or is it acceptable to request that the attending personnel keep their comments to a minimum? If our care is compromised because of our piercings/tattoos, i.e. being offered less pain medication or being “stabbed” with blood-drawing needles, how do we document and report it? How should we brush aside a psychological consult, especially those who do not possess a concurrent mental illness as I do? Piercers often have resources that mention modification-friendly medical personnel, but how could we go about finding those for ourselves? How should we prepare for medical emergencies that may involve the removal of unusual piercings, such as genital piercings or lobe-stretchings?

Thank you for your aid. If anyone wishes to contact me directly, I would like to compile answers and make them available to others so that our encounters with the medical profession are more pleasant.

Wow, that’s a lot of questioning! You are entitled to the same treatment as any other patient – respectful and complete. You don’t deserve to be ridiculed or made fun of. You deserve as much pain medicine as you need to be comfortable. I’d think it would be acceptable to request that your body not be discussed at the nurse’s station. People tend to talk about things they don’t understand to share their views with their coworkers to see what they think. It happens, but it’s not respectful to the patient. If you feel that your care is being compromised, ask to see someone in charge – this can be a charge nurse or shift/nursing supervisor. When reporting your concerns, be respectful, calm, and nonthreatening. People who get bent out of shape and start going off on us, regardless of whether they are tattooed or pierced, DO NOT get much sympathy from us nurses.

If after talking with someone in charge you still feel that your care is being compromised, by all means… ask to talk to someone even higher up. The manager of the unit, for example. I realize that hearing comments or feeling that your care is substandard would be extremely frustrating, but please try to keep your wits about you when speaking with Those In Charge. (And that goes for anyone with a gripe, btw). Unfortunately in this day and age, we can’t easily “vote with our feet” when we don’t like a hospital. A psychological consult should not be routinely requested just because a patient has a bunch of piercings, regardless of where they are. If one is requested anyway, just be yourself when the psychiatrist comes a-callin’. Don’t be argumentative, try not to be offended. If you are truly mentally healthy, a good psyciatrist will be able to determine this.

As for preparing for medical emergencies, I guess I’m not sure what you mean. If emergency medical treatment requires us to remove your piercings to provide care, I’m not sure what else you would have us do. Can you clarify the question?

And as always… if any readers have anything to add, please do so in the comments. My stance is this – to each his own. I have treated patients with unusual piercings (nipples, genitals) who were in comas… I just left the piercings alone and tried to clean around them when needed. Some nurses made some “ooooo, can you believe where she’s peirced?” comments, but they died down after a day or so. People like to talk about things that are unusual to them. Was it fair to the patient? No, but I didn’t see the comments as being disparaging, only curious. As always, if the patient were going for an MRI or something, all piercings would have to be removed to protect the patient. I don’t really think it’s a big deal and am not sure why others do.

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Questions About A Brave Decision

“Maggie” commented on the last post and had several questions. Since she didn’t leave an e-mail address, I figured I’d answer them here.

Hmmm. Hi. Interesting. There are somethings I don’t understand. Maybe you could help me understand, geena? Thanks.
1. He had “some acute renal failure.”
He was being dialyzed.
The dialysis machine then went kaput.
So he he must have been getting more swollen with fluid.

Well… in a matter of speaking. The machine was only off for about 2 hours, and it wasn’t like I was taking off a whole lot anyway; he wouldn’t have tolerated normal dialysis, which is why we were doing gentle dialysis. Gentle dialysis means that we could only take off a small amount of extra fluid each hour. So he WAS getting more swollen with fluid, but it wasn’t causing his current problems. The machine clotting off is just something that sometimes happens.

Then he started having breathing problems…why? Was this related to his kidneys or something else?
It sounds like he was “bucking” the ventilator if that is the right word. That is the reason for the paralytics, no?

He was kind of bucking the ventilator (which means the patient tries to exhale at the same exact time that the ventilator is attempting to give a breath, and it’s all out of sync). He was creating an auto-peep, or “stacking breaths.” Basically, he wasn’t exhaling completely before the vent gave him the next breath. He wasn’t overbreathing the vent, which was the wierd thing… it was just that for some reason, he wasn’t letting out all that was going in.

It sounds like he had a breathing problem aside from the kidney problem.

His lungs, remarkably, were clear. But the pH of his blood was extremely acidic, which made him do the “guppy breathing” we see in this case – almost a gasping, even though they’re being ventilated and are well-oxygenated. It’s weird, and a little hard to explain.

2. Once the dialysis machine was fixed, you were getting ready to put him back on, and the wife said stop?

It doesn’t sound like the medical team had decided that the patient was “unsaveable”. Did the wife really understand? Ie. was this an informed decision?

Yes, it was an informed decision. We did actually think that the patient was unsaveable, but it is not usually our place to stop treatment just because WE think that it is futile. In this day and age, there are a LOT of things that we can do to people to provide treatment, even though the medical team thinks it won’t ultimately save the person. The family makes those decisions and we try to guide them as best we can, in an honest and objective manner.

3. When the wife asked you if he was getting better, you replied you didn’t think he was. Then she said go ahead and disconnect, and you did.

Is this the way it is normally done?? Sorry, I’m just trying to understand! I was under the impression that such serious issues are normally discussed with the medical team ie. doctors, residents, specialists, nurse).

When the wife decided to disconnect apparently based on what you had told her, how is it possible to immediately do that? Shouldn’t such an order come from the medical team, or specialist, or someone? Can the nurse decide to disconnect without any physician/team input, based on what the nurse felt about his medical condition?

Such important issues ARE discussed with the physicians!! When families ask me if their loved one is getting better or worse, I ALWAYS want to tell them that they’re getting better. But I also believe in honesty, and the family needs to know what’s going on. I think sharing my assessment with her was just a mere piece of the puzzle in terms of her decision. She could see him swelling with fluid, she could see his color getting worse… I was merely confirming for her what she already knew deep-down. I didn’t feel as though telling her that I thought he was getting worse was a big revelation for her and I don’t think that she based her entire decision on it. He had been fighting for his life for about a week and we had done everything we could to save his life, but it just wasn’t going to be.

Having said all of that, it is NOT within a nurse’s scope of practice to initiate OR withdraw medical treatment from a patient without a physician order. I didn’t mean to imply that that’s what happened. Since all of this occured on the day shift, 2 of the patient’s doctors were readily available in the unit. After I told the patient’s wife about her husband’s condition, she talked it over with other family members and then talked it all over with both physicians. Both doctors fully supported her decision (as they had fully supported her decision to initiate all of the treatments were were doing) and they gave me the order to start a Morphine drip and extubate the patient, stop all other medications, and stop dialysis.

I hope that answered your questions (which were great, by the way!)

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A Brave Decision

Apparently getting the death card WAS a premonition.

A man in his 50′s was brought to our unit about a week ago. He had a chronic illness (although not likely to kill him anytime soon) but had developed some acute renal failure and liver problems. He was very ill for several days, sedated on a ventilator and although he showed some signs of improving, he mostly showed signs of decompensating.

The family was a very typical family that we see: this medical stuff was pretty much new to them and I spent as much time as I could educating them about what was going on. The decision was made to place the patient on CVVH, seeing as how his renal function was not getting better and he was becoming fluid overloaded.

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Alltop. I don't know how I got there either.


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    Profile for geenaRN

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  • profileI am Gina. I have been a nurse for 15 years, first in med/surg, then CVICU, inpatient dialysis, CCU and now hospice. This blog is about my experiences as a nurse, and the experiences of others in the healthcare system - patients, nurses, doctors, paramedics. We all have stories!

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