code blog: tales of a nurse

I had a really sad patient. She was in her 50's when diagnosed with cancer, and was given months to live. She survived well over a year but because her platelets were low, she bled into the lining of her brain. The evacuation of the hematoma (which requires opening the skull) was quite successful, but her platelet level just kept plummeting. One night her neuro status worsened, and she became "obtunded" ... basically, not responsive, but still breathing and such. A repeat CAT scan showed that she had re-bled. Her platelets were so low that they were unable to take her back to surgery, and so she was made to be a "comfort care" - we provide lots of morphine to ease her respiratory difficulty so that she can die in peace.

It was so awful for all concerned. She had a large, very devoted family. My normally reserved demeanor was certainly cracked. She basically died from the amount of pressure exerted on her brain from the continuous bleeding inside. It isn't a slow death, but neither is it fast. And it's usually not the prettiest site, either. I'm sorry that such things still have to happen. A good friend of mine once said, though, that sometimes we don't get the deaths we deserve.

Another irritating thing that happened recently had to do with a rather young patient that we had. She had TONS of specialists on her case: intensivists, pulmonologists, infectious disease docs, nephrologists, endocrinologists, and a cardiologist. No one knew exactly what was going on with this patient, as she had some pretty weird symptoms...

She seemed to be getting a bit better after a very rocky course, but one day, for no real reason, her heart rate shot up to the 170's. The nurse (not me) called the primary, general doctor, who said not to worry about it! Stupidity. That is so exceptionally irritating! How can you NOT be worried about such an awful heart rate? A heart rate that fast left untreated will eventually put the person into heart failure, or the workload could be too much and could cause a heart attack, or pulmonary edema, all of which are life-threatening, and all of which should not be happening to a young person.

Because I was in charge, I was asked to evaluate the situation. I told the RN who had her to call the cardiologist. He did. The cardio said that they'd signed off the case and weren't going to do anything about it. (What?!?) So then we call the intensivist/pulmonologist, and HE said to call the cardiologist. When informed that the cardio passed it off, he still refused to write any orders at all.

Finally we called the primary doc back and said that the patient was now finding it quite difficult to breath. That finally got us some orders for fluid - the doc thought she was dehydrated and her heart was working very hard to circulate volume that she didn't have.

So we gave her some fluid boluses, and her heart rate came down to 160, 150, 130, then her usual of 120's. Now, was that so hard? WHY did we have to call 4 doctors (the last was "on call" for the very first doctor, although not even 1/2 hour had gone by since we started calling. This necessitated the nurse to have to relay the whole situation AGAIN!) What if the nurse had just given up his concern after the conversation with the first doc? How long would it have taken for her to end up in a much worse condition?

Incredibly, it is a part of our job to constantly question MD orders. We automatically question every order - most pass the radar perfectly, but some, like this - require a lot of time and effort to advocate for our patients. NOT all doctors are so difficult to deal with, but every once in awhile we get some real gems. And sadly, this girl got lucky with the nurse that was assigned to her - some nurses actually WOULD have let it go after the first call.

Not with me in charge they wouldn't :-)