Donna, RN writes:

A young man died this weekend. He had a loving wife and a bouncing 10-month-old baby girl. Like all of us, he had a promising life, with many friends, many challenges, many opportunities and many wonderful dreams.

He came to us ill, but strong willed and hopeful. He had a medical team that was strong willed and hopeful. He had a family that was strong willed and hopeful, he had nurses that were strong willed and hopeful.

And yet, this young man died this weekend.

That day, amidst the turmoil and growing clutter of medical equipment crowding his ever shrinking hospital room there was a sense of collaboration, creativity, intelligence, hope and humanity.

It was the humanity that I clung to as we brought in the crash cart and began the final battle for his life.

He was young, maybe he could make it.

I let hope push back reality. Denial gave strength to our chest compressions. He was young, and his young daughter’s picture on the wall facing him gave that much more hope so I wouldn’t face despair.

We battled for him, with drugs, ventilation, compressions, anything and everything we had. We collaborated and encouraged each other. As I was getting exhausted from my turn at compressions, I felt the humanity in the room around me, and I heard myself saying, “Come on, M.” as I looked at his face and into his young eyes. The words felt naive and innocent, yet I had to give him the humanity and dignity of his fight. I knew I was saying goodbye.

This young man died this weekend. We all felt wounded as we were ripped from a delicate fabric, fraying ends weaving a bad dream. The nightmare for his wife and family had just begun.

It was cathartic to remove the signs of battle from that room, to restore calm and dignity to him and for his family. The emotional resonance of his death was palpable throughout the unit, as tears, anger, hugs and quiet sighs prevailed.

A young man died this weekend, and he put life and all its wonder into grand perspective.

I embrace the pitfalls, the pettiness, and the disappointments life can harbor, as the brighter, grander enlightenments of life prevail. The chubby hand of my granddaughter, the fighting heart of my biking husband, my dog’s warm, wet tongue, the “volunteer” rose that grew up amongst the lavender. These are what matters in life. This is the symphony that blends discord and harmony. Anything else is just so much noise.

A young man died this weekend, And he reminded me to let my heart sing.

Get out your crayon box! A new edition of Change of Shift is up over at Musings of a Highly Trained Monkey. Monkeygirl whipped up a very creative edition, and codeblog is proud to be jungle green :-)

Check out an award-winning Grand Rounds up at Vitum Medicinus. And find out what your favorite blogger’s favorite foods are!

I read a lot of ER nurse blogs. I know I’ve seen a lot – and I know they’ve seen much more. You think it’s an some kind of urban legend when you hear about patients coming in with a
broken nail (by ambulance no less! Where do these people come from?) but no – apparently it happens.

I’ve also noticed that some blogger ER nurses are frustrated by floor nurses. Girlvet says that floors in her hospital “refuse patients” or won’t take report because the admitting nurse is “busy” or “at lunch.” This causes a delay in getting the patient to the floor and ties up the ER bed even longer, causing patients to back up in the waiting room, patient dissatisfaction, the whole sequelae.

And ERnursey says, “Plenty of times when we are holding patients due to staffing there are nurses on the floors with all their work done sitting around the nurses station.” The title of that post is Why Nursing Ratios Are Failing Patients.

I won’t lie. I have seen charge nurses refuse patients to ICU (let’s see… supervisor calls over wanting to send us a 70 year old man who originally came in with low BP and low oxygen sats, but is tuned up after some IV fluids, is on no pressors, stable on some nasal O2 and yet he still has to come to ICU? Why?? Sorry, but I only have one bed left, and he ain’t takin’ it.) Tell me – what are the reasons given for floors refusing patients? I honestly don’t know.

In the past, I have seen instances of the nurse not being available to take report from ER. Yes, sometimes they’re at lunch. Before nursing ratios were actually enforced in my ICU, the person covering the nurse at lunch ALSO had their own patients in addition to watching the other two. That’s 4 critically ill patients. ICU patients are supposed to be at a ratio of 1 RN to 2 patients max. And those patients were wives, husbands, mothers, daughters, etc. Would you want your critically ill beloved family member being watched by a nurse who also has to watch 3 other critically ill patients? When they finally decided to start honoring staff ratios, we got a “break nurse.” This nurse watches patients for RN’s who are on a break, at lunch, etc. This means that when ER calls over to give report on a patient we’re getting, there is someone there to take report.

Nurses are also busy sometimes. Too busy to take report, even. I know ER likes to say that it doesn’t matter how busy they are, the patients still roll in. It also doesn’t matter how busy we are when there are critically ill patients in the hospital. We’ve had patients come over on balloon pumps from the cath lab with about 5 minutes notice, and code blue’s can happen any time. We have to respond to those and shift our staffing accordingly. So we are aware of what it’s like to receive very sick patients at a moment’s notice. But honestly – if we’re stuck in a patient’s room, elbow deep in poop, are we really supposed to drop everything to come and take report? I know in our unit, if the admitting nurse will be more than a few minutes, someone else will take report on his/her behalf. Sometimes there simply is no free nurse to do that. We do the best we can. It’s drilled into our heads on a daily basis that the ER is backed up and whenever they “go red,” all of the charge nurses find out about it and we try to help however we can.

As for nurses who are just sitting around on the floors while the ER is holding patients – come on now. I do believe you when you say that you’ve seen nurses sitting around, and when the opportunity arises for me to actually sit down and shoot the breeze with my coworkers, I take it. I also know that I have gone over to ER to borrow equipment to find them sitting around doing nothing while we’re 50 feet down the hall drowning in sick patients. It does go both ways. Are there patients backed up and waiting because the ICU is drowning? No, not always – but I say this to demonstrate that we do know what it’s like to be busy while other units are twiddling their thumbs. It happens in almost every unit.

Another reason for back-up is late transfers and discharges that go home later in the day. Docs discharge patients, but their ride can’t come and get them til the afternoon. Or placement has to be arranged, including transportation. ICU can have 5 patients that are able to transfer to the floor, but there will be no beds to transfer them to until later in the day. That causes back-up on our unit. I’ve also had this situation to deal with more times than I can count: ICU is full to the brim, with several patients to transfer out to med/surg, but there’s not a bed to be had by anyone. The supervisor will tell us time and time again: “Nowhere to transfer patients, all units are full (no beds) or no nurses to take the patient.” Then ER has a patient for us and viola!!! Somehow a bed has opened up on med/surg! Yes, a bed has just appeared out of nowhere, complete with a nurse to take the patient. Where was that bed/nurse combo 5 minutes ago? Who knows. We’re told, “Hey, ER has a patient for you, so go ahead and send bed 5 up to med/surg.”

All I know is that ER has been notified that ICU now has a bed and 30 seconds later calls to give report, but I haven’t even gotten the patient out yet! Why? Because I have to get the patient on a gurney, call the flex nurse to accompany if necessary, call transport to take the patient up. And I have to try to call report, too. I also used to get a lot of “the nurse is busy, she’ll call you back” or “the nurse is at lunch” before break nurses (ie, keeping-us-within-ratio nurses). I still get it when the nurse is there on the floor but is truly busy with one of his/her other patients. Maybe she’s in the middle of an important conversation with a family member, discharging a patient, teaching someone about how to prevent pneumonia, drawing up insulin, whatever. Am I supposed to insist on disrupting patient care? Well, sometimes I have. Sometimes I’ve begged someone, anyone to take report and give it to the accepting nurse when she gets a chance. Sometimes they’ll do it, sometimes they won’t.

And THEN we have to wait for housekeeping (sorry, Environmental Services) to come and clean the room. There are so few of THEM on the off-shift that you could wait up to an hour… and don’t even ask them to come when they’re at lunch. Forget it. You can say that you need the room cleaned emergently to admit an ER patient and if they’re on minute 5 of their lunch, the rest of the 25 minutes will be taken.

And it sounds bitchy to expect someone to come back early from their lunch. But I can guarantee you that almost every nurse has done it when the need arose. As a nurse, I have taken the patient up to the floor myself when flex and/or transport is tied up. I have even seen other nurses take a mop to the floor when EVS won’t or can’t come.

My point is that if we could have just transferred the patient when we got the orders, the patient would be out of the room and the bed cleaned and ready to go by the time ER calls with report.

There are many pitfalls to this system. Every unit experiences frustration with how things are done. I like the idea of having a person on-call to deal with admissions, but honestly? Sometimes we don’t even have enough nurses to deal with the patients already on the floors. Please don’t knock ratios, though, until you’ve walked in a mile in our shoes. You wouldn’t want your family member’s nurse to have 7 other post-op patients to take care of when research has shown lower rates of mortality if that nurse only has 4 other patients.

I’m not trying to pick on the ER nurses… we all have our perceptions. I appreciate reading about the frustrations of their jobs and hope they don’t mind hearing about the frustrations of mine. Any med/surg nurses want to chime in?

…Is up at Nursing Jobs.org! (The NJO blog!) Kim has done her usual amazing job of rounding up posts by the blogosphere’s nurses.

I don’t post frequently. When I do post, I’ve often thought about what I’m going to say for a long time – days, weeks. The topic sits in my mind like a spiky rock. My mind tumbles it until the remainder is smooth and coherent. Then I post.

But the article I’ve just read has set many many spiky rocks tumbling in my mind and it hurts.

This article, from the UK Times Online, describes a physician who withdrew treatment from two neonates when their conditions were discovered to be terminal. If you’ve read this blog since the days when I went on and on (and on) about end of life issues, advanced directives, and withdrawing treatment on terminal patients, you know that I fully and unabashedly support letting people die. I feel that in the majority of the cases I’ve seen and participated in, the family of the terminally ill patient is unable to let go and thus selfishly allows the patient to go on day after day, week after week – sometimes month after month.

I know it’s hard. It’s so hard to watch. It’s so hard to give up and accept that things will never again be the way they were. It hurts and it’s a horrible decision to have to make, but in some cases, it has to be made.

The physician in question decided in conjunction with the parents to “withdraw treatment” on 2 separate cases of very premature infants – both very sick and not expected to survive.

The infants were taken off life support and morphine was administered.

I’m totally with the good doctor so far. It’s all appropriate.

Death can be really ugly. When someone is removed from life support, it can be heartbreaking to watch. Often, the entire body is motionless except for the breathing motions that the patient makes. It appears as though the patient is gasping for breath (“agonal breathing”). I have always been told and taught that this is a very normal part of death and the patient very likely is not necessarily suffering. The reason is because they are dying and are not typically conscious (I’ve never seen anyone with agonal breathing conscious). Do I know this for sure? I admit it – no. I don’t think anyone does.

So what we do during this withdrawl of life sustaining measures is to give the patient morphine. Morphine suppresses the respiratory drive, relaxes smooth muscle of the body and has a sedative, as well as a pain relieving, effect. We start the morphine before even taking the patient off of life support. Despite getting this drug, some patients still exhibit signs of agonal respirations. If they do, I give them more. It’s (in my experience) widely acceptable to treat the patient’s symptoms, even if that treatment for their apparent suffering causes death. I have never given what I would consider to be a massive dose. I’ve always given small increments, assess the response after a few minutes and go from there.

So back to the babies. It is here that I start to disagree with the good doctor. I have not been in the situation, but it doesn’t take a stretch of one’s imagination to realize that watching your baby die is probably the hardest thing anyone would ever have to go through. It would break my heart and haunt me for the rest of my days to watch my dear sweet baby have agonal respirations. I would advocate for lots and lots of morphine to help alleviate any perceived suffering. Knowing that agonal respirations are normal in dying people does not go very far in comforting one having to watch them.

Apparently, presumably to treat the parent’s discomfort rather than the baby’s, the good doctor administered pancuronium. I found it laughable that the author of the article described it merely as a “muscle relaxant.” Pancuronium is a paralytic agent. Injecting this drug into someone paralyzes them, but does not sedate them. Sometimes we need to paralyze patients in the CCU (to treat them), and we ALWAYS give both a sedative and a pain reliever when this is done. Still… I always feel very uneasy about these patients because I’m never sure that they’re totally sedated. I’m fairly confident that they are, but that’s as far as it goes.

Thus, it makes me almost physically ill to think that those babies might have had one teeny tiny bit of consciousness… and were then paralyzed. I know what I said above – those patients with agonal breathing are likely not conscious. And the babies were getting morphine which would further the case for likely unconsciousness. But it just doesn’t sit right in my mind to actively stop them from breathing. Why couldn’t they just give more morphine? When giving enough morphine to relieve suffering, the purpose is to do just that – relieve suffering. There is a possible side effect of death. That last sentence sounds ridiculous, but the one and only goal is to make the patient more comfortable, not cause death. Giving a paralytic agent leaves no room for any sort of interpretation. If you give pancuronium to someone without respiratory support, you are doing so with the full knowledge that you will kill them.

The kicker quote of the entire article, for me, was that the doctor said that he was giving the baby a drug that “was on the verge of what society finds acceptable.” That sounds iffy at best. If some doctor told me that, I’d feel very uneasy. I mean – there’s experimental (maybe this will work, maybe it won’t) and then there’s socially unacceptable (unethical behavior?) Apparently the parents not only felt quite easy, they “fully supported the doctor’s actions and were grateful to him.” Goody for them, but I just can’t quite get it out of my mind that the “treatment” was done to comfort the parents and not the baby.

I’m sure that when it was not acceptable to give enough morphine to relieve a patient’s suffering, the mere thought of giving “too much” was enough to send spiky rocks in lots of other people’s minds. For all I know, someday giving a paralytic agent to someone having agonal respirations will be the standard of care.

I just might have to pass on taking care of those patients, though. I’m really quite sure that I could never do it. As I said – I didn’t take the time to mull this one over and it won’t surprise me in the least to discover that there are holes in my logic. I just had to get it off my chest.

Adding on – well isn’t this interesting. The Journal of Medical Ethics advocates the rare usage of paralytic to “allow a peaceful and comfortable death.” Sorry. Still can’t wrap my spiky rocked little mind around it. Judy at Tiggers Don’t Jump agrees, perhaps a bit more eloquently, too.

Hat tip to Kevin, MD for the article.

… At Aetiology. This is Tara’s second time hosting and she’s done a great job!

Pixel One, Purl Two is a nurse blogger who decided that we as nurses should take care of each other (‘cuz we don’t have enough to take care of?!) and has come up with an idea. She’s proposing a secret pal for nurses care package exchange starting next month. Details are here!
So yeah… in order to get a package, you have to send a package, but I personally think that’s fun, too :-)

If you’re coming here from Nursing Link and you’ve already read this article, click here to read my personal review of the movie!

“Ladies and gentlemen, I think we can agree on two things: The American health-care system is busted and Michael Moore is not the guy to fix it.”

And thus begins a rather scathing review of “SiCKO” by Stephen Hunter at the Washington Post.

According to Peter Barry Chowka at American Thinker, “The lead up to Sicko’s June 29 national roll out was a genuine phenomenon. Prior to its opening, with only a small number of reviews actually published, Sicko had already become the most hyped, and written about, movie of 2007, and possibly of the past decade.”

The past decade??

Is the actual film worthy of the hype that was created before its release? That depends on who you ask, of course. Hospital Impact has a very thorough Roundup of SiCKO reviews. As said in the comments, “My doctor recommends tests and procedures and medications, but ultimately, a healthcare insurance pencil-pusher decides what is “medically necessary” and reimburses accordingly.” Moore’s film reveals that the “pencil-pushers” are not necessarily your average Joe off the street, but instead are physicians who are paid handsomely for their expert opinions in denying your care – oops, I mean denying payment for your care.

Moore wasn’t necessarily interested in presenting both sides of the story, either:

“But one aspect missing from the film is the defense. Do not expect to hear anyone speak well of the care they received in the U.S. On the other hand, patients and doctors from Canada, Britain, France and Cuba marvel at their health care.”

‘Course, Moore’s missive doesn’t need to include a defense when you can simply get your information biased to the other side from websites such as Free Market Cure. As you can guess, this website is not exactly dedicated to the idea of socialized medicine, but instead puts forth ideas relating to consumer-directed healthcare. And what’s wrong with our system anyway? Here’s a theory:

“… Americans – whether privately insured or publicly covered – tend to be over-insured, and thus less sensitive to prices. And so we come to a paradox: American health care is so expensive because it’s so cheap. That is, with Americans paying just 14 cents out-of-pocket for every health dollar, they have little incentive to economize on health expenses. Americans have access to the most technologically sophisticated system in human history – yet pay pennies on the dollar out of their own pockets. The upshot? A health care system that is heavy in cost but not necessarily strong in satisfaction and uneven in quality.”

Several controversial issues are raised in this movie, including personal accounts of insurance companies denying payment for life-saving procedures and 9/11 workers having problems getting adequate health care for conditions they contracted due to working at ground zero. Moore also tackles the incident that happened last year when Kaiser dumped a confused and disoriented homeless patient in the middle of Skid Row. Slate Magazine’s Austin Goolsbee doesn’t disagree with Moore’s assertion that America’s healthcare system is broken, but does take issue with his “policy prescription”:

“For Moore, though, the answer is not reform of the current system. It is having the government run it all. He sets out on a worldwide tour to show us how great a single-payer system is in countries that have it. And here’s where his policy prescription goes into overdrive.”

Yes, there are many people flinging their opinions about this movie around the internet, and employees at Google are no exception. A blogger for Google’s Health Advertising Blog suggested that the healthcare industry fight back. How, you ask? With ads, of course: “Moore attacks health insurers, health providers, and pharmaceutical companies by connecting them to isolated and emotional stories of the system at its worst. Moore’s film portrays the industry as money and marketing driven, and fails to show healthcare’s interest in patient well-being and care.”

The entry knocked Google off of its firmly neutral stance, and the blogger in question apologized, saying that she was expressing her own opinion, which did not represent the opinion of her employer.

And hey – if you’re the kind of person who likes to stay in the thick of it all, consider joining this coalition: “Calling it the “Scrubs for SiCKO” campaign, organizers will recruit registered nurses and doctors to every theater in the nation where “SiCKO” opens to ensure that caregivers – in SiCKO scrubs-are in the audience.

The caregivers will distribute information and urge moviegoers to join the drive for a fundamental overhaul of the nation’s dysfunctional healthcare system – as is so brilliantly described in “Sicko.” They will urge the audience to help pass single-payer/Medicare-for-all-type legislation such as HR 676 now pending in Congress and several states, and make it a central focus of the presidential campaign.”

Whatever your opinion of Moore’s movie may be, whether you consider it to be brilliant, misguided, or blatantly inaccurate – even if it doesn’t reveal the perfect solution, realize that at the very least, it is creating a national dialogue about the quagmire that is healthcare in America. And there’s nothing wrong with that.

(more…)

Patricia, RN writes:

In nursing practice, I have found that a sense of humor is one of the most valuable instruments of healing. In a caring event, it provides relief and hope as an alternative to the pain and fear of the illness. For me, the nurse, humor provides a self-healing outlet from the intensity of focused energy needed to be fully present with the patient regardless of the outcome. The same healing instrument is used, although differently, to meet the needs in both the nursed and the nurse during the caring event. Drawing on the healing instruments of laughter and play within the midst of tears and high technology has provided me with some of the most memorable moments in my nursing career.

When I went home to care for my mother during an acute and potentially life-threatening phase of her illness, I took Ruggles, a large, soft, and very huggable therapy bear on the plane with me. Although we boarded the plane together, it was the last I saw of him until after landing. I seemed as though everyone, even businessmen, in formal three-piece suits, wanted a chance to enjoy a moment with Ruggles.

He was treated to his own ‘Pilot Wings’, given special treatment by the flight attendants, and asked to assist in the cockpit during the landing procedures. Due to his celebrity status, we were given BIP treatment through the airport to catch our connecting flight. The news of Ruggles and our mission had gone before us. After our final landing we were transported directly to the hospital in a special airline limousine.

The story of our most ridiculously fun flight experiences and the formality of our arrival, via limousine, brought back my mother’’s smile and a twinkle of mischief in her eyes. Fortunately, this was the perfect tonic to initiate the courage and strength needed to cope with the immediate health crisis. There was nothing within my training that could have provided a more positive healing environment than bringing her Ruggles.

Ruggles continued to enjoy his celebrity and healing status throughout her hospital stay. There were photographs, articles in the hospital review, and special visits to the pediatric, adolescent, and oncology inpatient units. One bear and a nurse, with a fun sense of the ridiculous, brought healing, love, and laughter to people from New York to Illinois. My mother recovered to the point that she could return home and continue at a more comfortable level of wellness for several more months.

My mother flourished in ways that would not have otherwise been possible and kept this piece of fantasy and fun as a charm to help her though the bad days. Her medical care interventions were completely met during that time at home by a wonderfully caring and competent Hospice treatment team. Although proud of my technical skills and knowledge, she didn’t need that part of my nursing practice. It was my ability to live nursing as an art form of care and caring that allowed her to share life, laughter, joy and healing during those last few weeks. My development into a highly skilled artisan within the caring practice of nursing intuitively allowed for the need to share tears of sorrow and loss as well as the hope there would be joy.

I am a nurse: I don’’t just provide nursing care, it is who I am. I became aware of the uniqueness that belonged only to nursing. I didn’t settle for nursing, I actively chose nursing as my vocation and profession. Florence Nightingale’s vision of nursing excellence enabled me to understand that no one can be what nurses are except a nurse. It was so easy, so clear. Nurses nurse. My nursing practice is an art form of caring within a highly scientific and technologically based health care environment. It is through nursing that I facilitate, enable, and empower the nursed.

In the final analysis, I believe a successful treatment outcome within our high technological care environment is ultimately patient defined and reflects how well the nurse’’s technical care was balanced by the interpersonal art of caring. This, from my perspective, defines nursing excellence in practice.