I took care of an elderly man recently.  He’d been dealing with multiple medical problems for almost 30 years.  Despite being in some very significant pain, he still made eye contact, still said “please” and “thank you.”

He wasn’t faking the pain.  He was very stoic, but I could tell he was hurting.  That tight-lipped grimace, the tachycardia, not moving a muscle unless it was absolutely necessary.  Still, manners prevailed.

My colleagues and I went above and beyond for him and his family.  There’s just something about being polite to others that makes those others want to help you and help you and help you some more.

I’m not saying that we don’t want to help those that aren’t overly polite.  It was just nice to be treated, well, so nicely.  I wouldn’t expect everyone in severe pain to maintain such decorum.  Every once in awhile you just click with a patient and it makes being a nurse so enjoyable.

So!  News #1.  Another of my posts has made it into a book.  It’s called “Lives in the Balance” and was edited by Tilda Shalof, who has written quite a number of books about ICU nursing.  I have read some of those books, so when she personally asked for one of my posts to be included I was quite flattered!

I’ve read the whole book, which is full of very compelling stories written by nurses who work in ICU.  I highly recommend giving it a read, and not just because one of my little posts made it in!

News #2 will only be news if you don’t follow me on Twitter or Facebook.  I am just over 10 weeks pregnant!  We are over the moon about this and can’t wait to meet him or her in late July.

And I guess the bonus news is that this blog is 7 years old this month :-)

He knew she was angry with him.

“Whenever I come to see her, I reach out and take her hand, but she looks away.”

Husband and wife for well over 50 years, they had been through a lot.  They met in another country in another time, and to hear him tell it, it almost seemed fated that they’d end up together.  Since then, they’d moved many times, raised a family, supported each other through myriad illnesses.  They were growing old together.

Unfortunately, “growing old together” doesn’t always work out like we hope it will.  Diseases and illnesses ravage our bodies; dementia ravages our brains.  She’d long ago given up on their little garden in the backyard.  It was her favorite hobby, but she couldn’t manage it anymore.

She had dementia, and she weighed less than 100 pounds.  Though not a result of her dementia, she was unable to eat properly and had slowly grown smaller and smaller.

She had done all the right things.  She was a nurse and she knew how these things could go.  She had an advanced directive filled out; not only signed and dated, but specific treatments and procedures were addressed – feeding tubes, antibiotics, tests, organ donation, resuscitation – really almost everything you can think of.

Many people designate a DPOA – Durable Power of Attorney – along with filling out an Advanced Directive form.  When in a condition where making one’s own decisions is impossible, a DPOA is a person chosen by the patient (in advance of illnesses and while the patient is considered competent) to make decisions for them.  The hope (for us, as healthcare workers) is that the patient has had a long, frank discussion with their chosen DPOA as to what their wishes are.

In her case, although they may have had this talk, her wishes were also explained in great detail in a written document.  A document that we had a copy of in her chart.  A document that her family readily provided to us.

In the condition she was admitted in, she would need IV fluids, antibiotics, x-rays and tests.  She wasn’t completely unconscious, but she wasn’t very coherent either.  Add in her element of dementia, and it was clear that she wasn’t able to make decisions.

Her family waited quite awhile to bring her in.  They were managing her pneumonia at home until she started having trouble breathing.  That is when they brought her to us.

And this is where she and I met.  They only thing she would say to me is, “I want….” but would never finish the sentence.  She seemed to really want whatever it was and I hope I was able to provide it with everything I tried.

Her husband came in to see her, and this is when we had our conversation.  He told me that he knew she didn’t want any of this.  Definitely did not want a feeding tube, but that’s the direction we were going to have to go in in order to treat her.  He said that he knew she didn’t want it, but that he was her Power of Attorney, and it didn’t matter to him – he was going to ask us to give her one anyway.

It was obvious he was grieving and in denial.  There was no malice, only a very matter of fact manner.  And a deep underlying sadness.  It appeared to me that he was simply unable to carry out that which she had painstakingly directed.

He assumed that this was the reason for her anger; the reason that she wouldn’t look at him anymore.  She had trusted him not to put her through this.

I sometimes take care of patients that are clearly terminal.  They often don’t have their wishes written out in a detailed manner; many people don’t even understand what we as medical professionals are capable of doing to them to keep them alive.

My patient knew.

But she chose a person who was unable to follow her wishes when the time came to actually make the heart-wrenching decisions.  We assume it’s our spouse or closest family members who would be our best advocates, but sometimes that isn’t the best way to go.  Of course, then you are stuck choosing someone that will have to go against your family at a most critical and emotional time.  Do you know anyone strong enough to advocate for you?  To make sure your wishes concerning end of life care are honored?

I very gingerly tried to get him to tell me why he would go against her wishes, but he wasn’t able to give me a straight answer.  I could tell that he already missed her so much.  I hope she can forgive him.

Just over a month ago, our unit had several H1N1 flu patients.  And they were sick.  Really really sick.  They were also fairly young – 30’s to 50’s.  I wondered at the time why the media hubbabaloo about the flu had died down when I was seeing more and more patients in my unit who had it.

Last time I worked there was only 1 flu patient and they weren’t too sick (yet?) to require a ventilator.  I was really glad to see the decrease in this particular patient population.  I won’t lie – it’s frightening to be a nurse caring for someone with a highly communicable disease.  Masks, gloves, gowns are all provided by the hospital, but I can’t ever shake the feeling that I’ve somehow come in contact with it despite these precautions.

And what of the times that we admit patients and don’t know they have a communicable disease?  At least one coworker I know of contracted H1N1 from taking care of a patient who had it before we knew they had it.

I’m sure she was quite shook up – every single patient who turned up positive for the flu in our unit in that time period ended up literally fighting for their lives on a ventilator.

The most harrowing patient we had was a woman in her 30’s who was pregnant.   Like the other patients, every time she coughed on the vent, her oxygen saturations would decrease to the 80’s and would take a long time to come back up.  Unlike the others, though, she was so fragile that sometimes merely coughing on the vent caused her to go into asystole.

I’m somewhat jaded about coding people at this stage in my career.  I remember, as a brand new ICU nurse, talking to a well-seasoned ICU nurse.  She said that hearing “code blue” being announced overhead didn’t give her any kind of adrenalin rush anymore.  At that time, I couldn’t imagine being in that frame of mind.  Being new, I was expected to go to every code blue that was called so as to get experience.  My heart started going into SVT at simply hearing the word “code.”  If the word “blue” came after I practically had to defib myself before running off to defibrillate the patient.

I eventually got to a place where I could fairly confidently go run a code without freaking out.  I’ve been an ICU RN for 11 years.  In those 11 years, there have been some awful codes.  Two stand out in my mind, and the absolute worst was on the pediatric floor.  When I heard “code blue, pediatrics” overhead, my first (naive) thought was, “little kids code???”  My second thought was to wonder if it was really an adult overflow patient.  Sometimes the gyne surgeries went to the pediatric floor if there was no more room on the surgical floors.  You know, maybe one of them got a little too much morphine and the nurse called a code.  A little Narcan, a few bagged breaths and everyone would sigh with relief and go on with their day.

No such luck.  After running full speed up 3 flights of stairs, I arrived at the room that had the most people spilling out of it only to find a bald, thin 5 year old in the bed.  I thought I was going to be sick.  PICU nurses – bless you all.  I could not do that for any length of time.

She didn’t make it.  Having been a nurse for a couple of years at that point, my naivety about the world already had a few chips and cracks in it.  But on that day a huge chunk fell out.

Since then I’ve come to be more like that seasoned ICU nurse that I spoke with so early in my career.  Along with the semi-jaded “oh crap, a code blue” comes a confidence in one’s abilities, so it’s not all bad.

However, watching that woman go into asystole, knowing that we would have to crash c-section her if she stayed in it?  That took me back to the days when I was new and inexperienced.  I’ve never seen anything like that happen.  Although I was perfectly comfortable with my (pre-arranged) personal role, the overall situation would be completely new to me.

Although HIPAA prevents me from saying much more, I will say that I did not have to experience that situation; not because I was off when it happened but simply because it never happened.

If it had, it surely would have made my top 3.

This story was related to me from a coworker:

I was taking care of a man who was on bipap.  (Bipap is a form fitting mask that goes over the mouth and nose to help augment breathing.  It has successfully been used numerous times in place of intubating patients and putting them on ventilators.)  He was becoming restless and tired of the mask.  I had to wait for the doctor to come and see him, though, before I could remove it.

Due to his medical condition, it was very important that he get an aspirin that day.  Since I couldn’t give it to him by mouth (because of the mask), I had to explain to him that I’d need to give it rectally as a suppository.

He nodded his consent and I proceeded to give the aspirin.

A short while later, the doctor came to see the patient and agreed that we could take the bipap mask off for awhile.  I happily entered the patients room to take the mask off… and before it was even off his face, he stuck his finger in the air and said,

“FOR THE RECORD, that is a hell of a way to take an aspirin!!”

It’s a hell of a way to give one, too.

A few years ago, my hospital updated our computer charting/order entry system.  When a doc orders a med, the system is set up to make the order expire in a set period of time (2 weeks, for example).  During training, we were taught that when it was getting close to the time of expiration, an alert would be sent to nursing and to the doctor who ordered the medication so he/she could renew it if they wanted.

I never agreed with sending the alert to nursing.  I’ve always thought it should just go to the doc that ordered the drug.  Why create a middle man?  Anyway, I almost always ignore these alerts since I know the docs see it too.  They’re really annoying because they pop up randomly even if you are in the middle of something and you have to acknowledge it before you can continue with your task.

We are now upgrading our system and I recently had to go through another training session.  The instructor told us that this new upgrade still has the feature as described above, except for one thing – doctors would no longer receive the alert.  The medication expiration alert ONLY goes to the nurse.

Me:  “Why won’t the doctors be receiving the alerts anymore?”

Instructor: “I don’t know.  Maybe they complained about it enough to have it removed.”

Me (smiling):  “So if we nurses complain about it enough, we might be able to get rid of it too?”

Instructor:  “No no no… no one listens to nurses.”

I would have dismissed it as an offhand comment if it hadn’t been delivered with an utterly absolute lack of humor.

I realize that as annoying as those alerts must be for me, they must be extremely annoying for the doctor.  I only receive one or two a shift, but they must receive numerous alerts throughout the day.  Still… what am I supposed to do?  Drop everything and call the doctor everytime an order for the patient’s stool softener is about to expire?  Wouldn’t repeated phone calls from nurses be WAY more annoying than clicking a few screens?

One of our patients came off sedation and was extubated.

A few hours later, the doctor came by to assess the patient’s mental status.  He asked,

“How old are you, Mr. Smith?”

The patient replied, “I was born in 1924.”

It wasn’t really the answer the doc was looking for, so he asked again,

“But how old are you?”

And the patient looked up at the doctor and said,

“You do the math.”

Heh.

I am late in linking to Change of Shift this week, so there it is.  Kim hosted this week and she has some questions at the end for nurse bloggers.  Go weigh in!

Girlvet at Madness: tales of an emergency room nurse recently posted something I’ve been thinking about a bit lately:

There are times at work when I am astounded at the amount of information that we are expected to absorb. Honestly it is hard to think of another job in which new information is given, and expected to be remembered, on a daily basis. And the information is not simple it is often complex. New drugs, procedures,etc. I’ve had the thought of trying sometimes to write down what we are asked to retain. It would fill an encyclopedia.

I work every other weekend.  That amounts to one day a week.  Do you remember how you feel at work after a 2 week vacation?  That’s how I feel at work all the time.

I used to feel pretty competent at work, and I still do.  But more and more I’m going into work and finding that I don’t know a whole bunch of things.  I don’t make it a rule to refuse patient assignments, but a couple of months ago I had to do just that.  Both patients assigned to me were on the same IV drip – a drug I had NEVER worked with before.  And both patients were being titrated frequently.

I felt pretty lame admitting that I didn’t feel comfortable taking the assignment.  I have routinely taken the sickest patients in the unit – multiple drips, CVVH, etc.  I would still feel comfortable taking the sickest patients as long as I were familiar with the drugs being infused.

Every time I go to work, there’s some new piece of equipment, a new technology (most recently hypothermia therapy and abdominal pressure readings) we’ve just implemented, or a different way of doing a procedure.  I’ve been trained in everything, but when you go months and months between learning something and then getting a chance to implement it, things get a bit rusty.

I hope I can stay current enough to at least keep taking the “easy” patients.

Best wishes to everyone for a happy and healthy 2009.  Happy new year!

I’ve written before about the myriad of sounds in the ICU environment. That post mostly dealt with IV pumps beeping, ventilators alarming, and constant talking. But there is one sound that will always rise above the cacophony: the soul-deep sob of someone who has just gotten the worst news of their entire lives.

The average office worker, barista, pilot or librarian may never hear that sound their whole life. Even for a nurse who works in a critical care area, I would say it’s fairly infrequent. Most people take devastating news rather well in public. Some people are so shocked that no sound could come out even if they wanted to cry.

You may think you’ve heard it on TV shows or seen it in a movie. But not even the best actor in the world could accurately capture it well enough to shake the dark recesses of your psyche when you hear it just a few feet away.

There is not one other sound that I can think of that would put such a halt to a busy nursing station. Hearing “code blue” overhead would momentarily reset us into action. Hearing the fire alarm barely fazes us anymore. Some crazy person running through the unit screaming would startle us, but we’d immediately get over it and take care of the situation.

But when we hear the muffled cries of someone who is trying to escape the unit, we never know if they’re going to make it to solitude. Sometimes they don’t. People have literally fallen into a heap on the hallway floor mid-step when their bodies just can’t hold the horror in another second.

It sends a chill down every single one of us and we are momentarily paralyzed by it. Humans (in America at least) are usually very guarded with our emotions. We don’t want to be vulnerable in front of a bunch of people we don’t know. So when we hear such a raw and primitive sound coming from another person, a stranger, it resonates very deeply. The sound is like a tangible thread that darts out to everyone within earshot and for an instant ties us all together.

One or two of us will break out of our paralysis to go to the person, but the rest of us are stunned into silence. What do we do? Do we stand there gaping at them, or do we turn back to our charting, our conversations? It’s disrespectful to gawk but then again, it’s disrespectful to go on as though someone isn’t falling apart 3 feet away from us.

If my coworkers are anything like me, it put them into sort of a daze for the rest of the day, too.

… but didn’t:

Travelers getting requested cancellations are almost unheard of. I know that has not been the case since you joined us, but take it from me – these are usually very rare occurrences.

I did not make you join this staff as a traveler and thus inherit all of the injustices that the position comes with. If I remember correctly, though, you are very well compensated.

I did not make the policy which dictates that regular staff get cancellations before you do. I just have to follow it.

It does not matter that you asked for the cancellation before everyone else. The only thing that matters is the numbers.

Having said that, it was not I that requested and received enough cancellations to put your numbers higher than the other traveler’s numbers. That was all you.

Was it an extra kick in the pants to have to take that traveler’s patients so she could go home early instead of you? Why yes. Yes it was. Serendipitous even.

Being in charge is sometimes a real pain in the ass. How unfortunate that the irritation this time had to come from a professional colleague.

This weekend we had a patient who had come in with chest pain. He was taken to the cath lab and was stented.

Normally this kind of patient would go home in a day or two if there were no complications. Unfortunately this patient had a big complication – he was an alcoholic. So by the time he was ready for discharge for his heart problem, his alcohol withdrawal had kicked in.

He is now on day 5 of his stay at the hospital. He spent at least 4 of those days in ICU which costs many thousands of dollars a day. He was still there Sunday afternoon when I left, and still on his Ativan drip. He was nowhere near getting transferred out to the floor.

I’ll cheerfully bet you $100 that even after all of the hell his body went through detoxifying from alcohol, he will get some good ‘ol ETOH from somewhere within an hour of leaving the hospital. You see, when he started getting goofy from DT’s, we started drugging him. Probably with some oral Valium at first, then when that didn’t work, we hit him with some continuous intravenous Ativan. Once the worst of the DT’s passes, we wean him off IV Ativan back onto oral Valium. When he’s stable on that, he gets discharged. I admit that I don’t know exactly how that works, because we just transfer them to the floors. Does he get sent home? Does he go to some alcohol treatment center? I have no idea.

I do know that some of our detox patients are in ICU because they have presented to the ER for whatever reason and request to be detoxed. They’ve had enough; they want off the sauce. Even the relapse rate for this is high; I often see the same patients come back over and over again. And those patients want to detox.

But when alcoholics come in for other health problems, they are detoxed whether they want to be or not. It’s for staff and patient safety, you know. People going through DT’s can be very combative and can be dangerous to themselves and others. So if they don’t get out of the hospital before the shakes hit, they automatically buy themselves a week’s stay… or longer.

This practice is downright counterproductive. If the patient comes in with a health problem, they should be assessed (as they currently are) for their alcohol intake. If it seems that the patient is an alcoholic, they should be counseled about it (”you should really stop drinking, you know”) and then be allowed to make their own decision. If they choose to keep drinking, they should be allowed to drink in the hospital. I know there are all kinds of possible ramifications to this idea, and I’m not talking about letting patients get sloshed. But if a beer or three a day will keep the DT’s at bay, then they get a shorter hospital stay. Which would taxpayers rather pay for? A case of beer or a $40,000 hospital bill?

Obviously it would not be a good idea for everyone, but I believe that it would be very helpful for some. I can’t tell you how many patients I’ve seen who come in for some minor surgery (appendectomy, chole, etc) and end up with all kinds of complications because we decide that they need IV Ativan more than they need a glass of wine or three at dinner.

They’re adults. It is utterly ridiculous how we healthcare providers think we should fix every little thing about a patient when all they need is a stent and a bus ticket back home.