code blog: tales of a nurse

I regularly tie people up.

I'm not immensely proud of it (or even a little bit proud of it) but I guess it's quite necessary.

Imagine that you're in a deep sleep. You hear noises; your level of conciousness rises a little. More and more you realize that you're uncomfortable in so many ways. Your back hurts, your limbs feel heavy, your arms are sore, even your nose feels out of whack. Since you're still only very partially awake, you try to see if you can move somewhat. You can, but feel as though the command that originated in your brain took at least 10 minutes to reach your arm, which is still trying to obey.

Meanwhile, the unfamiliar noises persist. You feel as though you're stuck in a sci-fi movie. Beeps, blips, talking, scraping, phones ringing... that doesn't sound like your phone at home. None of these voices are familiar. (And why hasn't the message from your brain made it to your feet yet?) Your eyelids feel as though they are stuck shut.

Then you realize... you aren't breathing. How can that be? All of a sudden, your mind is moving faster than it ever has, trying to figure this out. You realize that your throat hurts, it feels full. Your mouth is dry. You aren't breathing. In the fraction of a second, all of your senses have fully come alive and the commands your brain is sending to your limbs are speeding up. You try to take a breath (God, it's like breathing through a straw!) but right at that exact moment, a woosh of air is being forced down your throat from this straw. An alarm explodes right by your head and the combination of all that air has irritated your lungs. You start to cough. An even more annoying alarm goes off right by your ear. What the heck is going on? What is this straw that won't go away? Getitawayrightnow!

So, half asleep, groggy, disoriented, you pull out your endlessly annoying endotracheal tube. The very tube that's keeping you nice and oxygenated.

That's why we restrain people. So that when they start reaching for tubes and wires that were very difficult to place, they are unable to remove them, or tug at them. Seems kind of barbaric, huh? But removing tubes almost always necessitates the re-insertion of tubes. If it's a breathing tube, the interval between removal and reinsertion could be very dangerous for the patient, as they are not being oxygenated well. Pulling out an ET tube that has not been deflated could cause vocal cord damage. At the very least, replacing a nasogastric tube or foley catheter is just downright uncomfortable.

Even if the patient is starting to take breaths on their own, they still may not be well or awake enough to breath completely on their own yet. That annoying nasogastric tube may still be draining gunk from the stomach - without that tube, they may become nauseated and start vomiting. And if you're in the ICU, chances are very good that you've received a foley catheter.

We nurses don't really like restraining people. For some of us, it's a visceral reaction - we simply do not like tying people up. For others, it's a question of paperwork. Restraints require a hefty dose of paperwork. Paperwork that has to be constantly updated, no less. All in all, it's one of those "necessary evils." We cannot be at the bedside at all moments, because we usually have another patient to attend to. Sometimes if family is around and they seem trustworthy, I'll take the restraints off the patient and the family can deal with them trying to pull things out. But I've been burned before - sometimes family members get tired of doing that, but neglect to tell the nurse that they're leaving the room. Henceforth, the patient remains alone and unrestrained, and tubes are inevitably dislodged.

I usually tell families that the patient is sedated (which is usually the case) and is in a state where they don't know exactly what's going on. So if they become concious even a little bit of all these tubes, their primal reaction is to remove the source of discomfort. They don't realize that they are removing life-sustaining tubes; they are just trying to get that thing out of their mouth so that they can go back to sleep. We nurses always try to be at the bedside when a patient is starting to wake up so that we can reassure them, remind them of what's going on, or give them more juice to return to sleep.

There are all kinds of restraints: wrist and ankle bracelet restraints that we tie to the edge of the bed (prevents the patient from bringing their hands to their mouth, or prevents them from throwing their legs off the bed), vest restraints that prevent them from exiting the bed, or my favorite: mitten restraints. Mittens go over a person's hands and on the palm side are very very thick. When applied properly, the fingers are unable to grasp anything. Therefore, you can usually remove wrist restraints, leaving the patient to move their arms about as they like. They won't be able to grasp tubes to pull. However, some patients are definitely able to get out of these.

I'm sure it's pretty scary to experience what I described in the beginning of this post. I'm sure it's even scarier to try to reach for the thing that's causing you discomfort and find that you are unable to move your arms. When a patient is waking up, I always remember to tell them that they are restrained, and that is why they can't move just yet.

I still feel bad to have to do it. Hopefully there is not a special hell reserved for us.