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.

Wow. Life has been rather busy lately. I recently moved, my grandmother passed away necessitating a last-minute trip to the midwest, I’m in the process of starting a business and am chasing after a 16 month old. Oh, you want to see a picture? Ok!

Work has been as busy as ever, with both the regular and overflow units open. Lots of sick people this time of year as usual. Lots of scrambling for transfer orders so that we can get more sick people in. It’s a revolving door.

Primarily working weekends, I am more attuned to the Weekend Syndrome now than ever before. This syndrome is characterized by a lack of decision making on the part of doctors who are covering their partner’s patients on the weekend. I’m assuming that the covering doctor gets a sign out from the doctor who is off (usually – sometimes not) and they round on the patient over the weekend.

Normal decisions about a patient’s care are typically made – adjusting medications and vent settings, transfer orders, that sort of thing. But if you are the patient and you are anywhere near close to death, forget it. The status quo is maintained at all costs. Is it somehow taboo for a covering doctor to make end of life decisions over the weekend? Apparently it is!

My patient, in his 50′s or 60′s had had a cardiac arrest and thus ended up with the usual trifectic sequelae of shock liver, kidney failure and ileus. Apparently he’d been in CCU for about a week. No family in the picture, and thus no one to make decisions on his behalf.

Of course he was a full code.

Perhaps it was just because I was seeing the situation with fresh eyes, but after looking at his hideously disfigured labwork, it was pretty obvious that this poor guy wasn’t going to make it. And yet 5 doctors rounded on the patient, and only one of them was familiar with his situation. The rest were covering for the weekend. Every single doctor looked at the patient, wrote a note, and went on to the next patient.

The next day when I arrived on the unit, I found that his condition has worsened. I figured that withdrawing the vent and CVVH was too lofty a goal, so I aimed to at least change his code status to “no code.” If his heart was to stop, I didn’t want to have to shock him or do CPR. People who are that sick do not come back from the dead when we code them; or if they do, they certainly don’t stay long.

As each specialist rounded on the patient, I informed them of his labs (worse than the day before), his labile blood pressure and the fact that I was needing to go up on his pressors. We were all pretty much in agreement that his prognosis was very poor.

Despite this poor prognosis, each doctor suggested getting a head CT scan. And that is what we did. I still to this day cannot figure out why we did that. Maybe it would have shown a bleed, or maybe it would have revealed that he had cerebral edema. It could have confirmed the diagnosis of anoxic or hepatic encephalopathy. But as the doctors discussed this amongst themselves, it was stated that there was no effective treatment for any of those findings. Oddly enough, although each specialist said that they wanted a head CT, not one of them would order it. It was up to the hospitalist to order it. She knew next to nothing about the patient and when I called her for the order, she could not have cared less about why the other doctors wanted it. “If they want it, go ahead and get one.”

When I asked the cardiologist about at the very least making him a no code, he pretty much came out and told me that he wasn’t going to do that because it wasn’t his patient. I asked if we agreed that the patient was probably going to die soon. He said yes. I told him that I wasn’t even asking to withdraw the vent – I just didn’t want to code the guy. He flat out told me that it was the responsibility of the patient’s usual doctor to make that sort of decision. Everyone concurred. Every time I asked about making him a no code, they all said that it would be addressed the next day… Monday. When the usual docs would be back around.

Meanwhile, my patient required frequent cleaning due to the lactulose he was getting. His blood chemistries were so out of whack that he was literally breathing over 40 times a minute. The highest rate I saw was 47. Go ahead – try to breathe 47 times per minute. See how comfortable it is before you pass out.

Because the usual doctors weren’t on, this patient laid in the bed another day. Not to sound crass, but in addition to his probable suffering (I actually don’t think he was conscious, but who knows for sure), he was using a critical care bed and his treatment required that he have one nurse to himself. Believe me when I say that many many thousands of dollars were spent on him during that day alone.

Why? Because we were waiting for family to come in from out of state so that they could say goodbye? Because one of his loved ones just couldn’t bear to let go yet? Because the doctors truly felt as though he had a fighting chance?

Nope. It was because the doctors who could make the decisions were off that weekend and no one else stepped up. If it happened here, it’s happening elsewhere, maybe many elsewheres.

Add it up.

I know you know that our patient was on isolation, because it’s very hard to miss: 1) the big red “ISOLATION” sign on his door, 2) the big cart outside of his room containing gowns, gloves, and masks, and 3) me, standing at the patient’s bedside wearing said garb. So when you come in ungowned and unmasked and I say, “Um, you do know that this patient is in isolation?” the correct response is not to hold up your gloved hands and say, “It’s okay; I’m gloved up.”

When told that this patient requires more personal protection equipment than gloves, the other correct answer is not, “I don’t have time to bother with that shit. I’m not touching him anyway.” Do you want to know how I know that this answer is incorrect? Because when you were bending over ever-so-slightly to listen to the patient’s chest using your own stethoscope instead of the dedicated isolation stethoscope, the front of your shirt poofed out just a little, and just enough to brush the side rail. The side rail that has been touched by many many gloved hands probably containing all kinds of millions of organisms that are, you know, resistant to more than quite a few antibiotics.

And the “I don’t have time to bother with that shit” comment? I did point out to you that I have to put on the gown, gloves, and mask every time I walk into the room, which was easily 1-2 times an hour, sometimes more often. For 8 hours. So you do not have to tell ME about what a pain it is to bother with it. I am well aware.

You did get one thing right. As you walked out of the room, you very correctly used the alcohol hand gel… and when I told you that the one of the organisms that the patient has does not respond to alcohol gel and that you need to also wash your hands, your snotty reply of “I know that, Geena” was a little unexpected. If you don’t even know enough to use proper isolation technique, how am I to know that you know anything else about it?

And finally, when I remind you to clean your stethoscope, your answer of, “I already did that” is not fooling me at all, because I have been watching you closely out of the corner of my eye and I know full well that not only did you not clean your stethoscope, you handled it after washing your hands, thereby contaminating yourself again. Well, it was going to happen regardless. I wish it hadn’t happened before you started putting your grubby hands all over the chart, though.

And although the pen that was sitting on the counter right next to you was my favorite pen, I threw it away after you were done “borrowing” it.

Right before I called the epidemiology nurse and told her alllll about you.

Awhile ago, I read a post from The Angry Pharmacist about Wal*M*art’s $4 prescriptions. I really felt for his point of view – after all, isn’t W-Mart responsible for putting zillions of mom-and-pop stores out of business? And over the years I’ve heard about them skimping on their employee’s health insurance. I’ve always had the impression that W-Mart is pretty much squashing “the little guy” out there with its giant yellow smiley-faced foot.

Of course I’d heard about their $4 antibiotics. Is that what they started with? Just antibiotics? I was unaware that they’ve expanded their $4 drug list considerably until this weekend.

My patient was in the hospital for heart failure. We got him all tuned up, the docs tweaked his meds a little, and I was all set to discharge him. While talking to the doctor at the desk, I learned that the reason the patient had landed in the hospital with heart failure was because he was noncompliant with his medications.

I stopped caring about patients complying with their treatments a long time ago. Well, maybe it isn’t that I don’t care. Maybe it’s because I’ve never really seen anyone “shape up.” I’ve educated patients over and over and over again about the importance of taking their meds only to have them bounce back a month or two later due to their noncompliance. People are human – the best you can do is educate. What they do with that education is up to them. You can lead the horse to water and all that.

Anyway, the doctor wrote seven prescriptions for the patient to have filled. He had already been taking some of the medications, but many others were new. After I went through each prescription, explaining what the medication was for, I put them on top of his discharge papers and went about unhooking him from the monitor, etc. He’d been plenty chatty all morning, but he was suddenly very quiet.

He picked up the seven scripts and then put them down again. He said he didn’t know how he was going to be able to pay for all of them. He said his insurance did not cover prescription drugs. I didn’t ask him, but I wondered if that’s the reason why he was noncompliant.

I left his room and asked another nurse if she thought that one of the social workers could provide him with some resources to help him with this problem. She said she didn’t know if they could or not, but why didn’t he just go to W-Mart and get them filled there? I said I thought that it was just for antibiotics, to which she replied, “Um, no.”

So I went to the internet, hopped on W-Mart’s website and printed out the list of medications that are $4. I went through and highlighted every. single. medication. that he was prescribed. All 7 were on the list. I took the list in to him and his daughter and suggested that maybe they try W-Mart for their meds. They looked at me with deer-in-the-headlight eyes. I told them that I found every med on the list, and that barring any restrictions (some meds are priced higher in CA due to state laws, apparently), he’d only have to pay $4 for each drug.

They just stood there looking at me incredulously. I was starting to feel a little weird until they turned to each other and smiled. My patient asked if he had to sign up for something, or have a specific insurance, and I told him that I didn’t think so from what I read on the website.

The relief in the room was palpable. Then they started calling me an angel from heaven and all that, so I had to admit that it wasn’t my idea :)

Just for kicks, I looked up how much each medication would have cost otherwise. I admit that I have no idea if what I was looking at was at all comparable to what they cost off-line, but by using W-Mart he’d save well over $100 per month. I would imagine that that’s a substantial amount of money for someone on a fixed income.

I’m not naive enough to think that money was the only factor in my patient’s non-compliance. But I do know that he was perfectly happy taking the medications I gave him. He even inquired as to what each one was and what it was for, which is something I cannot say for the vast majority of my patients. The ones who are conscious anyway. So although I am not naive to reality, I am hopeful that his noncompliance was due to economic reasons and not apathy.

Before I sent him home, I walked with him and his daughter around the unit to see how he tolerated activity. When we returned to his room, his daughter remarked that he seemed to be walking faster than he had in a long time. He agreed and added that he didn’t feel out of breath, either. Here’s to hoping he stays that way for a long time.

I’m not sure what to think about this $4 per drug business. It obviously puts independent and other chain pharmacies at a distinct disadvantage. I am sympathetic to their situation, but it’s hard not to feel good about someone’s father, brother, uncle feeling better because the drugs they need are affordable for them. Thinking long-term, his compliance will also keep him out of the hospital, thus saving even more money and leaving healthcare resources available for the 90+ year old demented bedridden urosepsis patients that populate our unit. I wonder if W-Mart has a fix for that.

Oops, guess I let a bit of sarcasm slip out.

I had a patient a few weekends ago that was elderly and had many acronyms wrong with him (COPD, CHF, CAD, s/p CABG, HTN, DM, PVD, was HOH, CRF, past CVA, TIA’s and, um, osteomyelitis). During report, I asked the nurse to just tell me the diseases he didn’t have.

Anyway, his CRF was turning into a nasty case of ARF and the primary care doc came in and ordered renal-dose dopamine. Does anyone actually still prescribe renal dose dopamine? Well, obviously, because this one did. But does anyone else? Being the dutiful nurse that I am, I started it at a whopping 2mcg/kg/min and sort of rolled my eyes at the whole situation.

The patient was one of those cantankerous sorts that I love taking care of:

Me: I have to give you a shot in your abdomen. It’s a blood thinner that will help prevent blood clots in your legs.
Patient: In my stomach? It sounds like that will hurt.
Me: It won’t hurt that badly.
Patient: Who’s the patient here, me or you?
Me: I’ve had shots in the abdomen before. They aren’t that bad.
Patient: (regarding me warily) Well, okay…

After I gave him the shot, he winced and said, “I thought you said it wouldn’t hurt!!” To which I replied, “No, I said it wouldn’t hurt that bad.” Ha :-)

Anyway, about 15 minutes later, my patient started to desat. Out of the blue. I did all the usual things to fix it, but nothing worked. I finally resorted to putting an O2 mask on him. I went in later to turn him and he complained of being nauseated. I checked the residual on his tube feeding and got what I’d gotten an hour before – less than 10 cc’s.

A lot of weird things were suddenly happening with my patient.

Because he was nauseated, he kept taking his oxygen mask off. Then he would desat. I went to talk to the pulmonologist, hoping we could just sort of settle for a sat of 88% or so, but he told me to tell the patient that if he didn’t keep his mask on, I would have to restrain him. Come on!!! He’s an old man with some really bad acronyms!! Leave the poor guy alone! My advocating went nowhere, however, and I had no choice but to deliver the news: “The doctor says that if you don’t leave your mask on, I’ll have to restrain your arms.”

He looked at me as though I was nuts. Well, I felt nuts. The guy was quite oriented, not confused at all and here I am threatening him with restraints. Sometimes I really hate this job.

So I went back to the doctor and said, “Can I interest you in a Phenergan order for his nausea?” He was agreeable to that, but before he put the order in he paused for a moment. “But why is he nauseous all of a sudden?”

Well, a tiny little light bulb went on in my head and I smacked the doctor’s arm and said, “It’s the dopamine!” I remembered a patient we got from the cath lab a few years ago. The patient was on like 10mcgs of Dopamine and she was constantly green and dry heaving (Great for groin punctures!). It could be chalked up to quite a few reasons (pre-op medications, the fact that she’d just had an MI, etc) so I didn’t think much of it. No antiemetic worked, however. But as I came down on the Dopamine, her nausea started to abate. When we had to put her back on it a few hours later, it came back.

So I went back to my patient and turned off the Dopamine to see what would happen. He had no idea that I’d even started it or that I was shutting it off. 15 minutes later I went back in because his sats (which were about 91% on a mask) had risen to 96%. I asked him if he still felt sick to his stomach.

Nope. No longer nauseated. And his sats were up, so I put him back on nasal prong oxygen. The sats stayed up.

Has anyone else seen this? Dopamine, even at a ridiculously low dose, really screwed this guy up on a couple of different levels. I explained the situation and all he said was, “Yeah, I figured you were probably a good nurse.”

Well there ya go. Can’t argue with that.

Ohhhh I have been away for awhile. I did not think anything could rival my blogging addiction, but my husband wanted to get an Xbox. Many hours have been sucked up playing Catan, Carcassonne, and Viva Pinata :-) I am completely hooked.

Anyway.

A patient I had a few weeks ago was intubated, even though she told her family she did not want to be. When the chips were down, they chose to tube her. She was pretty pissed when the tube came out.

I tried to talk to the doctor about it. I told him she didn’t want any of this, and that her wishes should be respected. He said that she had been unresponsive at the time that the decision was made, the family chose to tube her, and in the absence of documentation to prove her DNI wishes, that was that. But the thing that really got me was this: “It’s between her and her family. I’m not getting in the middle of it.” He said that to me twice.

For some reason it really bugged me that he said that. Isn’t that our job? To get in the middle of it? I understand the lack of documentation, but he brushed it all off, wanted to get on to his next patient.

The other thing that bugged me: When he came to see her, he sat at the computer, looked at her labs, wrote a note and left. He didn’t even go in and see the patient. Was it because she was sedated on a vent? Or was it because I was doing a sedation vacation on her and she was actually awake but difficult to communicate with?

It is very difficult to communicate with people on ventilators. They try to talk but they can’t. It’s hard to lip-read around a tube. If you untie the restraints to let them write they either go for the tube in their moment of freedom, or what they write isn’t legible. Communication boards are a nice idea, but when someone’s coming off sedation, their limbs feel as though they weigh a ton. It’s actually quite difficult for an elderly person to even hold their hand steady enough to point at a picture. If they can even see the pictures and words.

Still, I managed to ascertain that she was ready for the tube to come out whether the docs thought it was appropriate or not. It took me a long time to figure this out and I had to watch many bouts of frustration while she tried to get her message across. Many patients gesture wildly and when the guesses I proffer aren’t correct, the frustration in their faces is heartbreaking. They sometimes literally throw their hands down and close their eyes in defeat.

It’s hard when people who are in charge of your well-being can’t understand what it is you’re saying. It’s scary to be tied down to the bed with a tube you never wanted stuck in your throat while you wait for test results to come back. Test results that determine whether we remove the offending tube, or whether we put you back to sleep to wake you up another day and try again.

I managed to figure out what she wanted, though. It took some time, lots of guessing, and perseverance. It took some patience waiting for her to get over her frustrated moments enough to try again. And then, finally, the tube came out, and she confirmed her wishes to me immediately.

After all that… I summarize the major plot points for the physician and all I get back is, “I’m not getting in the middle of it. She needs to work it out with her family.”

Well good for you. Problem solved (for you). Now you can get on to the next patient. You may as well have written your progress note from home and faxed it in for me to put on the chart. Enjoy the fee you collected on your “patient visit.”