“Do you have any sensation in your body?” I ask. Mr. Murphy is a little annoyed by the question. Does his nurse not know anything about him? “I am a Quad,” he mouths (he is on a ventilator, so he cannot speak). “I know that,” I say, “Some quads have sensation.” This is apparently a new piece of information for Mr. Murphy and he pauses, pleased, to chew on the new bit of knowledge. ‘What would that be like? Would it be better or worse?’ I imagine he was thinking like that.
Mr. Murphy was a patient that other nurses tried to avoid. Unlike most ICU patients, he was very sharp mentally. His situation was so frustrating to him that it had driven him to the edge of madness. When you took care of him, his lips would run a mile a minute as he told you urgently whatever was on his mind and especially what he wanted you to be doing. You could not understand any of it, and I think the other nurses found this disconcerting. He would generally ignore requests for yes or no answers, so you were left to try to figure it all out on your own. Every move you made seemed to increase his frustration.
I stopped him and told him that I wanted to do what he wanted, but could not follow him at all. In this way, I extracted a few begrudging yes’s and no’s. When he found me responsive to these, he slowed down a little and I was able to catch a few words here and there.
He wanted a speech valve for his trach so that he could talk. I told him that valves only worked for patients who are not on ventilators. He insisted emphatically that that was not the case and that he had had one before. I agreed to call speech therapy. The answer came back as I expected – no such thing existed. I told Mr. Murphy. “Thanks for trying,” he mouthed.
He could not even talk. He was helpless. He could only feel his head, and on the back of his head was a large bed sore which had just been cleaned and debrided. A white circular area the size of a yarmuka (about 5 inches in diameter) was his skull. This was the result of neglect.
Mr. Murphy was the poster child for “I would not want to live like that,” but he did not seem to know it. He did not ask for death and he did not seem interested in it (not that I asked). While I still think that, in similar circumstances, I would want to be allowed to go, I did not feel the emotional resistance in myself that one often feels when taking care of hopeless cases. Mr. Murphy was psychologically intact, and I guess this made all the difference.
As the shift went on, I took opportunities to talk with him. I could not catch every word, but sometimes I could get enough to follow what he was saying. I tried not to ask him to repeat himself too much.
How had he been injured? He had had a minor neck surgery and had fallen just afterwards. I asked about the specialty hospital where he stayed when he was not in critical care. He shuddered, “A horrible place.” He told me something more about it, but I could not follow. Something about the people there not caring I think. From other sources I heard that his sister had tried to care for him at home and that the ulcer on his head was from that time.
I asked him what his work had been. He had worked in corrections as some kind of counselor. Did he like it? “Yes. I was good at it,” his silent words were full of feeling and memory.
As I excused myself, he thanked me, “It is not often….” I could not catch the rest although I have a pretty good idea sadly.
Mr. Murphy’s sister arrived in the afternoon. They were clearly close. I gave them privacy as they talked for an hour or so. What a difference it makes to have someone who loves you in your life.
Sunday, March 1, 2009
Thursday, February 19, 2009
Nursing on the High Wire cont.
The respiratory therapist tried for the blood gas on the other wrist. Another RT was getting ready to try when she hit the artery and the syringe began to fill with blood. The MICU resident arrived. He examined the patient. Was this CO2 narcosis? I brought up the issue of Mr. Jones’ code status. Was he DNI or not? I had spoken with a different doctor on the phone. The resident went to the computer and found a note from the MICU attending stating Mr. Jones should be DNI, but with what the patient had told me, did that still stand? Was the patient of clear mind when I spoke to him this morning? I assured the doctor Mr. Jones had had none of his current symptoms when I had spoken with him. Meanwhile the respiratory therapist was trying to ask the doctor to put the order for the blood gas into the computer. The machine that runs the lab test is hooked to the computer system and a physicians order is required for running a sample.
The MICU doctor was clearly flustered. He went to the Bipap machine to check the settings and went to the computer to check Mr. Jones’ labs and orders. He wondered out loud if this was being caused by a brain stem lesion. He wanted a stat head CT. I informed him that patients cannot travel on Bipap because the machines do not have any batteries. He was doubtful. The respiratory therapist confirmed this. He was still doubtful. He checked the Bipap again and examined the patient again.
Meanwhile the respiratory therapist was becoming exasperated. The doctor had said he wanted a blood gas over half an hour ago, but he had yet to put the order into the computer. The RT was turning the syringe gently in her hands, trying to preserve the sample, looking to get a word in edgewise to ask the doctor again to put in the order. He was not paying any attention to her. I looked around for more experienced nurses who would know how to put in a verbal order, but did not see any. I would probably be able to figure it out myself, but this did not feel like the right time to try. Finally I stopped him, “Doctor, please, both of us are a little new here and we are really unable to run the blood gas without an order.” He snapped out of it and sat down to put the order in.
The charge nurse had taken over my other patient and had gotten him some pain medicine. Anesthesia had now been paged multiple times both for the epidural that needed to be hooked up and for Mr. Jones who might be needing an emergent intubation. They had arrived on the scene now and wanted to know whether or not to set up shop. The MICU fellow and another resident had also arrived. I told them all about my morning conversation with the patient. The reaction was the same each time. At first they would say, “then he should not be DNI any more,” but after a few moments they would back track. It did not feel like they did not trust me, but that would have been reasonable since I was meeting all of them for the first time. Maybe the thought of Mr. Jones dieing on a ventilator was unappealing. Maybe the thought of explaining it all to the family was discouraging them.
They wanted to get in touch with the son, but he was not picking up on either of the numbers we had for him. There was not even an answering machine. The blood gas came back. PH 7.069, pCO2 123 – it was worse than I expected. Another ten minutes and Mr. Jones surely would have coded and died. If not for the DNI status, they would be intubating Mr. Jones now, but the doctors were still unsure what to do. The senior anesthesiologist was on the scene now. His resident explained that the MICU doctors were unable to decide if Mr. Jones was DNI or not. “Well they better hurry up and decide or he will end up DRT.” I do not know what DRT means, but I got the gist.
The fellow called the attending. Final answer – DNI. In the back of my mind I thought about how disturbing this would be for me if I was more attached to what was going on. Mr. Jones had told me clearly that he did not want to be DNI and the doctors were ignoring me even though I had told them about it before all of this had happened. I tried to keep perspective. What if Mr. Jones was intubated and became permanently vent dependent. He would not have wanted that either. “I am okay either way,” I told the fellow, “but his mind was clear this morning.” I did not want her to think I had some kind of agenda.
I turned to the charge nurse who was only one year out of school. She had caught the end of the conversation. I explained they were keeping Mr. Jones DNI. “That’s not what I would want for myself!” she blurted out. “I am trying to stay detached,” I said. The respiratory therapist was also upset. Should I make a scene and try to force the doctors to intubate? I was not feeling it.
Mr. Jones started to have moments of voluntary movement. He would get a few muffled words out from behind the mask and then go back into his trance. His arms were getting softer also, although they were still stiff. Over the next hour he returned to his baseline condition. A little good old-fashioned vigilance had saved the day. Whew.
When Mr. Jones could understand me, I told him that he had almost died and that he needed to tell the doctors what he had told me this morning. I told him that I had told the doctors about our conversation and that they were not going to listen to me. I did not elaborate because I did not want to disturb him unnecessarily. He seemed to grasp the situation well enough from what I told him. He wanted the mask off again. I told him that was not an option.
After another hour we took Mr. Jones up to the MICU. I checked his orders on the computer the next day. He had been intubated at 8:00 pm. I suppose I should have felt happy about that.
After two weeks, Mr. Jones was sent, still on the ventilator, to the MICU of a long term care facility.
The MICU doctor was clearly flustered. He went to the Bipap machine to check the settings and went to the computer to check Mr. Jones’ labs and orders. He wondered out loud if this was being caused by a brain stem lesion. He wanted a stat head CT. I informed him that patients cannot travel on Bipap because the machines do not have any batteries. He was doubtful. The respiratory therapist confirmed this. He was still doubtful. He checked the Bipap again and examined the patient again.
Meanwhile the respiratory therapist was becoming exasperated. The doctor had said he wanted a blood gas over half an hour ago, but he had yet to put the order into the computer. The RT was turning the syringe gently in her hands, trying to preserve the sample, looking to get a word in edgewise to ask the doctor again to put in the order. He was not paying any attention to her. I looked around for more experienced nurses who would know how to put in a verbal order, but did not see any. I would probably be able to figure it out myself, but this did not feel like the right time to try. Finally I stopped him, “Doctor, please, both of us are a little new here and we are really unable to run the blood gas without an order.” He snapped out of it and sat down to put the order in.
The charge nurse had taken over my other patient and had gotten him some pain medicine. Anesthesia had now been paged multiple times both for the epidural that needed to be hooked up and for Mr. Jones who might be needing an emergent intubation. They had arrived on the scene now and wanted to know whether or not to set up shop. The MICU fellow and another resident had also arrived. I told them all about my morning conversation with the patient. The reaction was the same each time. At first they would say, “then he should not be DNI any more,” but after a few moments they would back track. It did not feel like they did not trust me, but that would have been reasonable since I was meeting all of them for the first time. Maybe the thought of Mr. Jones dieing on a ventilator was unappealing. Maybe the thought of explaining it all to the family was discouraging them.
They wanted to get in touch with the son, but he was not picking up on either of the numbers we had for him. There was not even an answering machine. The blood gas came back. PH 7.069, pCO2 123 – it was worse than I expected. Another ten minutes and Mr. Jones surely would have coded and died. If not for the DNI status, they would be intubating Mr. Jones now, but the doctors were still unsure what to do. The senior anesthesiologist was on the scene now. His resident explained that the MICU doctors were unable to decide if Mr. Jones was DNI or not. “Well they better hurry up and decide or he will end up DRT.” I do not know what DRT means, but I got the gist.
The fellow called the attending. Final answer – DNI. In the back of my mind I thought about how disturbing this would be for me if I was more attached to what was going on. Mr. Jones had told me clearly that he did not want to be DNI and the doctors were ignoring me even though I had told them about it before all of this had happened. I tried to keep perspective. What if Mr. Jones was intubated and became permanently vent dependent. He would not have wanted that either. “I am okay either way,” I told the fellow, “but his mind was clear this morning.” I did not want her to think I had some kind of agenda.
I turned to the charge nurse who was only one year out of school. She had caught the end of the conversation. I explained they were keeping Mr. Jones DNI. “That’s not what I would want for myself!” she blurted out. “I am trying to stay detached,” I said. The respiratory therapist was also upset. Should I make a scene and try to force the doctors to intubate? I was not feeling it.
Mr. Jones started to have moments of voluntary movement. He would get a few muffled words out from behind the mask and then go back into his trance. His arms were getting softer also, although they were still stiff. Over the next hour he returned to his baseline condition. A little good old-fashioned vigilance had saved the day. Whew.
When Mr. Jones could understand me, I told him that he had almost died and that he needed to tell the doctors what he had told me this morning. I told him that I had told the doctors about our conversation and that they were not going to listen to me. I did not elaborate because I did not want to disturb him unnecessarily. He seemed to grasp the situation well enough from what I told him. He wanted the mask off again. I told him that was not an option.
After another hour we took Mr. Jones up to the MICU. I checked his orders on the computer the next day. He had been intubated at 8:00 pm. I suppose I should have felt happy about that.
After two weeks, Mr. Jones was sent, still on the ventilator, to the MICU of a long term care facility.
Wednesday, February 11, 2009
Nursing on the High Wire
I started the shift with two “floor boarders” – patients that did not need to be in the ICU and were just waiting for beds. It looked like it was going to be an easy day. I was relieved. This was my second week off of orientation and my first week had been a hard one. I had worked four twelve hour shifts back to back. On the third day I had expressed concern privately to one doctor about the way another surgeon had spoken with a family. My patient was certain to die. He had been DNI and was not going to have surgery, but his daughter had flown in from out of town and convinced him to go through with it. Now she sat by his bed weeping from time to time. I did not feel it was fair of the surgeon to tell her that her father had a 50-50 chance of getting better. I told the other doctor I was uncomfortable with it. I had not spoken with the family at all. Four hours later, while I was milking the patient’s catheter tubing for a few extra drops of urine, the surgeon came barreling in to the room to berate me for talking like that to ‘his intern.’ “If you do not think this patient is going to get better, you should not be taking care of him!” he fumed. I explained calmly that I did not see it that way. He continued to yell at me in front of everyone. I told him he needed to speak with my nurse manager and he went away. Everyone backed me up, but it remains to be seen what the long term repercussions will be.
The next day my assignment was changed so there would be time for ‘everyone to cool down.’ I watched as no one talked to the patient’s two daughters, their eyes pleading for someone to talk with them every time I walked by the room. I was busy with my new assignment – a patient who had been intubated not because of respiratory problems, but because he had fought with nursing staff. For two days he had been in a medicated coma. On the day I had him, we woke him up and extubated. I worked hard to reorient him as he awakened, reminding him where he was and telling him what had happened (the incision from a vascular procedure had become infected) every five minutes of so until his mind cleared. His family came. He cried because his face had not been shaved. One of the techs went out of her way to shave him. I stayed on the other side of the bed to try to keep him calm. He wrapped his large hand around my arm, above my elbow. “If she cuts me, I am going to rip your arm off,” he said menacingly. I brushed it off. By the end of the day, I was holding one arm down and a doctor was holding down a leg in addition to three point restraints while the attending changed the central line in his neck over a wire. To show how tough he was, the patient had grabbed the line and tried to pull it out. Who does that?
So I had been off for two days and now I had my floor boarders. The patient with the daughters had died the night before. The daughter from out of town came in to thank us and gave me a big hug like she knew about everything. I took one of my patients to his floor bed. I would get a patient from surgery sometime in the afternoon. For now, I just had Mr. Jones, a small man with chronic obstructive pulmonary disease (COPD) on a Bipap mask. He was DNI.
First thing in the morning, I had asked him if he knew he was DNI. He looked at me, uncomprehending. He asked to have the Bipap mask off. The mask is hooked to a machine that produces positive pressure when the patient breathes in and helps to keep the lungs open. The mask has to fit tightly to work and is always uncomfortable. It is also noisy and it makes talking almost impossible. The order was to keep the mask on until noon and then see how he did off of it. Since Mr. Jones was adamant that he wanted it off, I decided to remove it and see how he did. I would have to watch him to make sure he did not start to build up CO2 in his blood, but this usually comes on slowly. If he became lethargic I would put the mask back on.
With the mask off, we were able to talk. I asked him if he had given instructions about being placed on a ventilator. He knew what I was talking about. I asked him if he knew that his DNI order meant that we would not put him on a ventilator even if it meant he would die. He did not realize that. He thought about it for a moment, “I think I might still have a good year left. I do not want to go on a ventilator, but if there is no other way, I would want them to do it.” Okay. A little nuance can make a big difference. Mr. Jones was a MICU (medicine) patient. He was in the SICU (surgery) because the MICU did not have any open beds. I paged the MICU resident and told him that Mr. Jones did not really want to be DNI and that I had taken him off Bipap and that he seemed to be doing fine. The MICU resident did not come to see him, but I was okay with that. Mr. Jones was doing fine, and I could not even find a code status note in his chart. Maybe they had never gotten around to making him DNI in the first place. There would be plenty of time to sort it out.
My other patient came around 1:00 pm. He had an epidural in for pain control, but in spite of their promise to do so, anesthesia did not come back to hook it up. Soon he was in severe pain. I was in the midst of settling him in, paging anesthesia, trying to find someone/ anyone to write orders for pain meds and trying to stay on top of documentation. I glanced over at Mr. Jones. He still looked fine. His oxygen levels were still good. He was sitting straight up in bed with his head back a little panting a little like he had been. I thought I would just be extra careful and ask him if he was okay. I tapped his shoulder. He did not respond. I got closer. His eyes were open, but he seemed unable to move. I tapped him some more and tried to get him to talk to me. He was not able. I put the Bipap mask back on and called the respiratory therapist. She came to check him out. “I gave him a breathing treatment 20 minutes ago and he was fine then!” I paged the MICU resident. He told me to get a stat blood gas and asked me when the patient would be coming to the MICU.
The respiratory therapist began trying to get a needle into the artery at Mr. Jones’ wrist for a blood sample that would tell us more about how he was breathing. I took a phone call and found myself talking with Mr. Jones’ son. He asked how Mr. Jones was doing and I told him Mr. Jones was fine. I expected Mr. Jones to perk up in a minute or two and did not want to worry his son unnecessarily.
When I got off the phone the respiratory therapist called me over. She had not been able to get the blood sample, but was concerned. Why was Mr. Jones so stiff? Was he having a seizure? I felt his arms and hands. His elbows were straight and locked. You could move them with a little force, but they would push right back as soon as you let go. His fingers were also straight out and stuck together in the same way. I called the MICU resident again. “I was thinking you might want to come by and at least eyeball him. He is having some rapid changes…” He said he would come.
To Be Continued
The next day my assignment was changed so there would be time for ‘everyone to cool down.’ I watched as no one talked to the patient’s two daughters, their eyes pleading for someone to talk with them every time I walked by the room. I was busy with my new assignment – a patient who had been intubated not because of respiratory problems, but because he had fought with nursing staff. For two days he had been in a medicated coma. On the day I had him, we woke him up and extubated. I worked hard to reorient him as he awakened, reminding him where he was and telling him what had happened (the incision from a vascular procedure had become infected) every five minutes of so until his mind cleared. His family came. He cried because his face had not been shaved. One of the techs went out of her way to shave him. I stayed on the other side of the bed to try to keep him calm. He wrapped his large hand around my arm, above my elbow. “If she cuts me, I am going to rip your arm off,” he said menacingly. I brushed it off. By the end of the day, I was holding one arm down and a doctor was holding down a leg in addition to three point restraints while the attending changed the central line in his neck over a wire. To show how tough he was, the patient had grabbed the line and tried to pull it out. Who does that?
So I had been off for two days and now I had my floor boarders. The patient with the daughters had died the night before. The daughter from out of town came in to thank us and gave me a big hug like she knew about everything. I took one of my patients to his floor bed. I would get a patient from surgery sometime in the afternoon. For now, I just had Mr. Jones, a small man with chronic obstructive pulmonary disease (COPD) on a Bipap mask. He was DNI.
First thing in the morning, I had asked him if he knew he was DNI. He looked at me, uncomprehending. He asked to have the Bipap mask off. The mask is hooked to a machine that produces positive pressure when the patient breathes in and helps to keep the lungs open. The mask has to fit tightly to work and is always uncomfortable. It is also noisy and it makes talking almost impossible. The order was to keep the mask on until noon and then see how he did off of it. Since Mr. Jones was adamant that he wanted it off, I decided to remove it and see how he did. I would have to watch him to make sure he did not start to build up CO2 in his blood, but this usually comes on slowly. If he became lethargic I would put the mask back on.
With the mask off, we were able to talk. I asked him if he had given instructions about being placed on a ventilator. He knew what I was talking about. I asked him if he knew that his DNI order meant that we would not put him on a ventilator even if it meant he would die. He did not realize that. He thought about it for a moment, “I think I might still have a good year left. I do not want to go on a ventilator, but if there is no other way, I would want them to do it.” Okay. A little nuance can make a big difference. Mr. Jones was a MICU (medicine) patient. He was in the SICU (surgery) because the MICU did not have any open beds. I paged the MICU resident and told him that Mr. Jones did not really want to be DNI and that I had taken him off Bipap and that he seemed to be doing fine. The MICU resident did not come to see him, but I was okay with that. Mr. Jones was doing fine, and I could not even find a code status note in his chart. Maybe they had never gotten around to making him DNI in the first place. There would be plenty of time to sort it out.
My other patient came around 1:00 pm. He had an epidural in for pain control, but in spite of their promise to do so, anesthesia did not come back to hook it up. Soon he was in severe pain. I was in the midst of settling him in, paging anesthesia, trying to find someone/ anyone to write orders for pain meds and trying to stay on top of documentation. I glanced over at Mr. Jones. He still looked fine. His oxygen levels were still good. He was sitting straight up in bed with his head back a little panting a little like he had been. I thought I would just be extra careful and ask him if he was okay. I tapped his shoulder. He did not respond. I got closer. His eyes were open, but he seemed unable to move. I tapped him some more and tried to get him to talk to me. He was not able. I put the Bipap mask back on and called the respiratory therapist. She came to check him out. “I gave him a breathing treatment 20 minutes ago and he was fine then!” I paged the MICU resident. He told me to get a stat blood gas and asked me when the patient would be coming to the MICU.
The respiratory therapist began trying to get a needle into the artery at Mr. Jones’ wrist for a blood sample that would tell us more about how he was breathing. I took a phone call and found myself talking with Mr. Jones’ son. He asked how Mr. Jones was doing and I told him Mr. Jones was fine. I expected Mr. Jones to perk up in a minute or two and did not want to worry his son unnecessarily.
When I got off the phone the respiratory therapist called me over. She had not been able to get the blood sample, but was concerned. Why was Mr. Jones so stiff? Was he having a seizure? I felt his arms and hands. His elbows were straight and locked. You could move them with a little force, but they would push right back as soon as you let go. His fingers were also straight out and stuck together in the same way. I called the MICU resident again. “I was thinking you might want to come by and at least eyeball him. He is having some rapid changes…” He said he would come.
To Be Continued
Sunday, February 8, 2009
Resistance is Futile
The tipping point came for me while observing the facility’s interdisciplinary work session. The head nurse, a social worker and a psychiatrist were having their regular meeting where they went through the patients cases and discussed plans of care. In the middle of the presentations, the social worker brought up the issue of a request for transportation from one of the patients. She had a court date today. She was trying not to lose custody of her children. She had missed a previous court date because she had been in this facility. If she missed this one, that would be it.
Less than five minutes were spent on the issue. The first reaction was that it would be a headache to arrange for transport. The psychiatrist then asked the social worker about what she thought the patient’s capacity to care for her children was. The patient was challenged just to take care of herself, “She does not need those kids.” And that was it. No transportation would be provided. Next case please.
When the meeting concluded I sought out my clinical instructor. I told her what had happened. She told me I had misunderstood. She would arrange for me to meet with the social worker so that I could ask her about it. I flatly refused. I was sure I had not misunderstood and did not think the social worker would appreciate being called out by a nursing student. I saw it as an attempt by the instructor to put me in my place. No, I would not do it. I did not agree. I told the other students about it at the group meeting at the end of the day. It raised a couple of eyebrows, but no one seemed particularly concerned.
I was without support. I spoke with my nursing school advisor. She seemed to be somewhat sympathetic, but was not really open to hearing about my concerns. As a nursing student, I had no standing. I had no training or experience that qualified me to evaluate or comment on the workings of a mental institution.
I did not expect to change anything at the mental hospital. I just wanted to find someone I could talk with about it. Someone who could accommodate what I was seeing and talk with me about how to get through it all.
I could not contain the urge to resist. I was not getting any traction on the issues, so I fought against a grade on a paper that had been assigned as part of the clinical coursework. This way I would at least have a voice. The very premise of the assignment had offended me. I already had a BA with a major in psychology. In all the time I had spent in psyc undergraduate courses, I had not had any contact with patients of any sort. The reason was clear; qualification to offer counseling came on the level of graduate study. As nursing students, we had one psychology class and one clinical during the entire program. On the first day at the mental institution, I had been sent alone into a room with two inpatients and told that I should have a therapeutic interaction with them. I decided that it would be most therapeutic if I did not allow either of them to come between me and the door to the room.
The paper assignment was to transcribe a therapeutic interaction we had had with a patient and evaluate it according to the therapeutic principles we were learning. I wrote the paper on my own terms. I expected a C, but I got an F. I complained to my advisor. Maybe I was being punished for making trouble. My advisor was not very enthusiastic about the whole thing, but she set up a meeting with the director of the nursing program at the university.
I liked the director of the program. She was friendly to me. Her background was in pediatrics and I had sought her advice several times on how to care for my recently born son. My fantasy was that she would ask me privately what all this was about. She would listen and understand and would take steps to somehow at least make the psyc nursing program more appropriate. I was more emboldened when I heard from other students that my clinical instructor had once been the director’s teacher and had told her she would never amount to anything. ‘I am offering a good service to the nursing program and the director will be pleased with me,’ I told myself.
It did not quite go that way. In the meeting, my advisor was asked if she thought the grade was appropriate. “Yes, definitely,” she replied. If she had only told me beforehand she was going to say that, there would have been no need for the meeting. I saw it was hopeless. I accepted the grade. I was again offered the opportunity to rewrite my paper and I again declined. No one could understand why. It seemed lazy-crazy. There was no opportunity to explain myself. All of my anguish about the facility was totally irrelevant. I lost the respect of the director and never recovered it. I moved to the back rows for the rest of my nursing education and kept a chip on my shoulder. It was pedestrian versus SUV, just like I thought it would be.
Less than five minutes were spent on the issue. The first reaction was that it would be a headache to arrange for transport. The psychiatrist then asked the social worker about what she thought the patient’s capacity to care for her children was. The patient was challenged just to take care of herself, “She does not need those kids.” And that was it. No transportation would be provided. Next case please.
When the meeting concluded I sought out my clinical instructor. I told her what had happened. She told me I had misunderstood. She would arrange for me to meet with the social worker so that I could ask her about it. I flatly refused. I was sure I had not misunderstood and did not think the social worker would appreciate being called out by a nursing student. I saw it as an attempt by the instructor to put me in my place. No, I would not do it. I did not agree. I told the other students about it at the group meeting at the end of the day. It raised a couple of eyebrows, but no one seemed particularly concerned.
I was without support. I spoke with my nursing school advisor. She seemed to be somewhat sympathetic, but was not really open to hearing about my concerns. As a nursing student, I had no standing. I had no training or experience that qualified me to evaluate or comment on the workings of a mental institution.
I did not expect to change anything at the mental hospital. I just wanted to find someone I could talk with about it. Someone who could accommodate what I was seeing and talk with me about how to get through it all.
I could not contain the urge to resist. I was not getting any traction on the issues, so I fought against a grade on a paper that had been assigned as part of the clinical coursework. This way I would at least have a voice. The very premise of the assignment had offended me. I already had a BA with a major in psychology. In all the time I had spent in psyc undergraduate courses, I had not had any contact with patients of any sort. The reason was clear; qualification to offer counseling came on the level of graduate study. As nursing students, we had one psychology class and one clinical during the entire program. On the first day at the mental institution, I had been sent alone into a room with two inpatients and told that I should have a therapeutic interaction with them. I decided that it would be most therapeutic if I did not allow either of them to come between me and the door to the room.
The paper assignment was to transcribe a therapeutic interaction we had had with a patient and evaluate it according to the therapeutic principles we were learning. I wrote the paper on my own terms. I expected a C, but I got an F. I complained to my advisor. Maybe I was being punished for making trouble. My advisor was not very enthusiastic about the whole thing, but she set up a meeting with the director of the nursing program at the university.
I liked the director of the program. She was friendly to me. Her background was in pediatrics and I had sought her advice several times on how to care for my recently born son. My fantasy was that she would ask me privately what all this was about. She would listen and understand and would take steps to somehow at least make the psyc nursing program more appropriate. I was more emboldened when I heard from other students that my clinical instructor had once been the director’s teacher and had told her she would never amount to anything. ‘I am offering a good service to the nursing program and the director will be pleased with me,’ I told myself.
It did not quite go that way. In the meeting, my advisor was asked if she thought the grade was appropriate. “Yes, definitely,” she replied. If she had only told me beforehand she was going to say that, there would have been no need for the meeting. I saw it was hopeless. I accepted the grade. I was again offered the opportunity to rewrite my paper and I again declined. No one could understand why. It seemed lazy-crazy. There was no opportunity to explain myself. All of my anguish about the facility was totally irrelevant. I lost the respect of the director and never recovered it. I moved to the back rows for the rest of my nursing education and kept a chip on my shoulder. It was pedestrian versus SUV, just like I thought it would be.
Saturday, January 31, 2009
Visits to Saint Elizabeth's
Two nine year old boys, inmates of the mental hospital where I have been sent for nursing school clinicals, stand at a counter, waiting for their meds. A male nurse hands each one a small paper cup with a handful of pills inside. The boy on the right puts his cup to his mouth, leans his head back and dumps the pills in. As he is doing so, he looks up and reads the name that has been written on the bottom of the cup. “Hey!” he says through the pills. He brings his head forward and spits the pills back into the cup. “These aren’t mine, they’re Derek’s!” “Well give them to Derek then!” retorts the nurse. The boys look at each other, shrug their shoulders and exchange cups. Bottoms up again; together this time. “Good for you for catching that,” says the nurse.
I mention the incident during the student group time at the end of the day. Our instructor is equivocal: the nurse did not see that the boy had the pills in his mouth. I glance at the other student who was with me at the time, but there is no spark. We remain silent. If their minds cannot accommodate reality, what shall I do? The nurse would have had to go back to the med room to get more pills. He might have even needed to make a note or waste the first set of meds. If the boys were willing to take them, why go to the trouble?
Psyc clinicals are not going well for me. The place was all wrong and it was not because of the patients. I had long ago trained myself to catch and hold the discordant details – things that happen in a moment which do not fit with the plans or ideals but yet are quietly built in to allow the machine to run smoothly. I pay attention because I believe that in these details are the signs and markings of sorrow and oppression. I hear in the distance the chainsaws clearing the rainforests. I see millions of acres of beetle-brown pines and elm skeletons – unmourned. I see busses full of zeks plying anonymously through capitol streets and government torturers making their way home to their wives in the evenings. I see transplant victims begging for death and being ignored. I see a trillion fires burning on the earth, consuming everything until nothing will be left. I want to protest, but what would be the point. It would be pedestrian versus tractor-trailer or worse than that.
Group session with the teenagers. Twenty or so kids sit side by side with their backs to the wall of the large alcove. Two counselors sit by the entrance to the area. The population has some diversity to it, but it is mostly underprivileged young men with anger problems and more privileged girls with self destructive tendencies. The girls are “cutters” – they cut on themselves with knives. It is not that they are trying to kill themselves or make suicidal gestures; they somehow find some kind of release through self mutilation. It is a new trend, but there are quite a lot of them.
I am assigned to the room with another nursing student to observe the session. The inmates speak amongst themselves while the counselors talk to each other at great length about their personal home improvement plans and projects. I lose respect for my fellow student as she jumps in to the conversation enthusiastically. The children are being ignored and they realize it. They seem quite accustomed to it.
I look around the room. I overhear a conversation. One girl says to another, “How much do you cut yourself?” The other girl proudly extends her arm, displaying scabby lateral lines from wrist to elbow. “That’s all?” says the first girl disdainfully. She presents her own forearms, showing off fewer, but much deeper scars. The first girl withers. I look back to the counselors and the other nursing student. They are talking about building decks. After another half an hour a writing assignment is given out – a share something about yourself kind of thing. The counselors continue their conversation for another 15 minutes and then we spend half an hour going around the room sharing. They put their hearts into it more than I expected.
Another group session on a different day:
The room is smaller. It is the next younger age group. The counselor is confrontational. It is mostly boys this time. One of the boys has been acting out in the hospital. He is warned that if he keeps it up he will be sent to prison. The counselor tells him that the guards will beat him at the prison. They will put him in a straight jacket and toss him in a van. The guards will beat him in the back of the van all the way to the prison. “But I will complain!” the boy protests. “Who do you think is gonna listen to you? You are a mental patient. The guards aren’t gonna say anything. Do you think they will believe you or the guards - huh?” Translation – if you see a cop, run. Very empowering.
I bring it up at the end of the day, but the other nursing student is full of admiration for the counselor. Someone has to set these kids straight or they will get themselves into even more trouble. I guess that was the thinking. I could not really follow.
To be continued.
I mention the incident during the student group time at the end of the day. Our instructor is equivocal: the nurse did not see that the boy had the pills in his mouth. I glance at the other student who was with me at the time, but there is no spark. We remain silent. If their minds cannot accommodate reality, what shall I do? The nurse would have had to go back to the med room to get more pills. He might have even needed to make a note or waste the first set of meds. If the boys were willing to take them, why go to the trouble?
Psyc clinicals are not going well for me. The place was all wrong and it was not because of the patients. I had long ago trained myself to catch and hold the discordant details – things that happen in a moment which do not fit with the plans or ideals but yet are quietly built in to allow the machine to run smoothly. I pay attention because I believe that in these details are the signs and markings of sorrow and oppression. I hear in the distance the chainsaws clearing the rainforests. I see millions of acres of beetle-brown pines and elm skeletons – unmourned. I see busses full of zeks plying anonymously through capitol streets and government torturers making their way home to their wives in the evenings. I see transplant victims begging for death and being ignored. I see a trillion fires burning on the earth, consuming everything until nothing will be left. I want to protest, but what would be the point. It would be pedestrian versus tractor-trailer or worse than that.
Group session with the teenagers. Twenty or so kids sit side by side with their backs to the wall of the large alcove. Two counselors sit by the entrance to the area. The population has some diversity to it, but it is mostly underprivileged young men with anger problems and more privileged girls with self destructive tendencies. The girls are “cutters” – they cut on themselves with knives. It is not that they are trying to kill themselves or make suicidal gestures; they somehow find some kind of release through self mutilation. It is a new trend, but there are quite a lot of them.
I am assigned to the room with another nursing student to observe the session. The inmates speak amongst themselves while the counselors talk to each other at great length about their personal home improvement plans and projects. I lose respect for my fellow student as she jumps in to the conversation enthusiastically. The children are being ignored and they realize it. They seem quite accustomed to it.
I look around the room. I overhear a conversation. One girl says to another, “How much do you cut yourself?” The other girl proudly extends her arm, displaying scabby lateral lines from wrist to elbow. “That’s all?” says the first girl disdainfully. She presents her own forearms, showing off fewer, but much deeper scars. The first girl withers. I look back to the counselors and the other nursing student. They are talking about building decks. After another half an hour a writing assignment is given out – a share something about yourself kind of thing. The counselors continue their conversation for another 15 minutes and then we spend half an hour going around the room sharing. They put their hearts into it more than I expected.
Another group session on a different day:
The room is smaller. It is the next younger age group. The counselor is confrontational. It is mostly boys this time. One of the boys has been acting out in the hospital. He is warned that if he keeps it up he will be sent to prison. The counselor tells him that the guards will beat him at the prison. They will put him in a straight jacket and toss him in a van. The guards will beat him in the back of the van all the way to the prison. “But I will complain!” the boy protests. “Who do you think is gonna listen to you? You are a mental patient. The guards aren’t gonna say anything. Do you think they will believe you or the guards - huh?” Translation – if you see a cop, run. Very empowering.
I bring it up at the end of the day, but the other nursing student is full of admiration for the counselor. Someone has to set these kids straight or they will get themselves into even more trouble. I guess that was the thinking. I could not really follow.
To be continued.
Saturday, January 17, 2009
A Restraint Free Nursing Home
We heard from Donna, our instructor for the nursing section of hospital orientation, that there was an initiative to end use of restraints within the hospital. Out of necessity, ICUs were exempt, but the rest of the hospital was currently restraint free. The nursing home that was operated by the hospital had not used restraints for more than a year.
My interest was piqued. As I have mentioned before, I am not very fond of restraints, but they have always seemed an unavoidable feature of the work environment. When things like breathing tubes and feeding tubes are inserted into the body, it is the natural tendency of the patient to want to remove them. Combine this tendency with any kind of dementia, disorientation, or plain disagreement and the situation is intractable. It often boils down to choosing between restraining the patient or letting him starve. You cannot let him starve, so you have to tie him down.
Thinkers who have taken on this riddle tend to recommend sitters. If you can place a person next to the patient for one-on-one observation and guidance, that person should be able to accomplish as much if not more than the restraints achieve. Unfortunately, these thinkers are not nurses, or if they are it has been a long time since they actually dealt with patients. A sitter can really only be effective if the patient is willing to listen. It is not the sitter’s job to watch a patient and grab his hand just as he is about to pull the feeding tube from his nose. Such actions cause immediate escalation and are counter productive anyways. It is a very small percentage of restrained patients that can actually be helped by sitters – those who are forgetful but docile. Even then, to have the expectation that the patient will be watched 24/7 just to stop them from pulling on things is asking quite a lot of an underpaid and unenthusiastic sitter. I challenge my readers to spend just ten minutes in such service. Ask yourself if you could do it for eight or twelve hours at a time.
So how does the hospital manage it? Nursing home patients will be having less technology hanging from their bodies, but they must still have the occasional feeding tube and they will be more mobile as well. You may not have considered this, but people with dementia are not always the most cooperative and if a few nurses and nursing assistants are going to take care of a bunch of residents there needs to be a certain level of routine and order. Residents also need to be protected from each other. “But if they have figured out a way to avoid using restraints, maybe I should look in to working there,” I thought to myself as I wondered what their tricks could possibly be.
The answer came in the next section of orientation when we discussed the use of restraints. Did you know that padded mittens, fastened around the wrist with Velcro, are not restraints because they don’t restrict movement, they only stop a patient from grabbing things? Donna told us that she did not recommend these because they tend to remind the patients of boxing gloves.
If you fasten a Velcro lap belt at the back of the resident’s chair or wheelchair it is a restraint, but if you keep the Velcro in the front where a reasonably able person could release it on their own…it is not a restraint.
Rigid sleeves filled with Styrofoam pellets keep a patient’s arm from bending and thus prevent them from reaching, say, their noses and pulling their feeding tubes. Once called elbow immobilizers, these are now known as ‘Freedom Splints’ (I think they are French) and they are not restraints.
A tray snapped across the front of a wheelchair, which cannot be easily removed by the resident, is also not a restraint provided it is being used for some other purpose. “So make sure you always leave a glass of water on the trays so that you don’t have to count it as a restraint,” says Donna cheerfully. With all sincerity she seems to feel that all of this somehow represents progress.
“Ah…,” I think to myself, a little disappointed but not surprised, “so that is how….you document…. a restraint free facility.”
Oh, and by the way; all of those complications that Medicare will no longer be paying for – you know UTI’s and Decubes etc. – we have almost eradicated them all already.
My interest was piqued. As I have mentioned before, I am not very fond of restraints, but they have always seemed an unavoidable feature of the work environment. When things like breathing tubes and feeding tubes are inserted into the body, it is the natural tendency of the patient to want to remove them. Combine this tendency with any kind of dementia, disorientation, or plain disagreement and the situation is intractable. It often boils down to choosing between restraining the patient or letting him starve. You cannot let him starve, so you have to tie him down.
Thinkers who have taken on this riddle tend to recommend sitters. If you can place a person next to the patient for one-on-one observation and guidance, that person should be able to accomplish as much if not more than the restraints achieve. Unfortunately, these thinkers are not nurses, or if they are it has been a long time since they actually dealt with patients. A sitter can really only be effective if the patient is willing to listen. It is not the sitter’s job to watch a patient and grab his hand just as he is about to pull the feeding tube from his nose. Such actions cause immediate escalation and are counter productive anyways. It is a very small percentage of restrained patients that can actually be helped by sitters – those who are forgetful but docile. Even then, to have the expectation that the patient will be watched 24/7 just to stop them from pulling on things is asking quite a lot of an underpaid and unenthusiastic sitter. I challenge my readers to spend just ten minutes in such service. Ask yourself if you could do it for eight or twelve hours at a time.
So how does the hospital manage it? Nursing home patients will be having less technology hanging from their bodies, but they must still have the occasional feeding tube and they will be more mobile as well. You may not have considered this, but people with dementia are not always the most cooperative and if a few nurses and nursing assistants are going to take care of a bunch of residents there needs to be a certain level of routine and order. Residents also need to be protected from each other. “But if they have figured out a way to avoid using restraints, maybe I should look in to working there,” I thought to myself as I wondered what their tricks could possibly be.
The answer came in the next section of orientation when we discussed the use of restraints. Did you know that padded mittens, fastened around the wrist with Velcro, are not restraints because they don’t restrict movement, they only stop a patient from grabbing things? Donna told us that she did not recommend these because they tend to remind the patients of boxing gloves.
If you fasten a Velcro lap belt at the back of the resident’s chair or wheelchair it is a restraint, but if you keep the Velcro in the front where a reasonably able person could release it on their own…it is not a restraint.
Rigid sleeves filled with Styrofoam pellets keep a patient’s arm from bending and thus prevent them from reaching, say, their noses and pulling their feeding tubes. Once called elbow immobilizers, these are now known as ‘Freedom Splints’ (I think they are French) and they are not restraints.
A tray snapped across the front of a wheelchair, which cannot be easily removed by the resident, is also not a restraint provided it is being used for some other purpose. “So make sure you always leave a glass of water on the trays so that you don’t have to count it as a restraint,” says Donna cheerfully. With all sincerity she seems to feel that all of this somehow represents progress.
“Ah…,” I think to myself, a little disappointed but not surprised, “so that is how….you document…. a restraint free facility.”
Oh, and by the way; all of those complications that Medicare will no longer be paying for – you know UTI’s and Decubes etc. – we have almost eradicated them all already.
Saturday, January 10, 2009
Cath Lab
I found shelter from floating for a month or two in the Cardiac Cath Lab. They had just lost some senior staff and needed someone to fill holes while they were training the new people. For the sake of stability, I traded my precious three twelve’s for four tens (shifts a week). I worked in the holding room where I prepped the patient’s for their procedures and recovered them when they came out again. If you are interested we had generally between 20 to 30 or more procedures a day at somewhere around 20K a pop.
About a third of the patients had had heart transplants. These patients get a heart biopsy every week for the first 6 months or so after transplantation. It was a refreshing change to see so many healthy transplant patients leading essentially normal lives, a few of them even ten years out form transplantation. There were also some whose transplants had started to go bad. While still in good health, their terror could be compared to that of a person who has jumped out of an airplane to find the parachute will not open. You cannot get back to the plane and your old heart is in the garbage heap.
The biopsy patients did not need IVs – the tiny pieces of heart muscle were collected with a straight shot down the jugular to the heart. The procedure was simple and low risk and did not require sedation. The patients could come in at 7:30 am and be home by noon if everything went well.
The rest of the patients needed IVs, which gave me the opportunity to brush up on one of my weaker and least favorite nursing skills. I like putting them in about as much as the patients like getting them. Subsequently I have not become very good at it and that does not help matters. For two months I tried for as many as I could and I did get better at it, although Jay (a hard stick) would probably still be better served to ask for someone else.
Recovering the patients was all about pulling out “sheaths” (large bore ‘IVs’ that protect the blood vessels when the catheters are passed through) from necks and groins. One day I may do a post about the built in discrepancies between what is done and what is documented. Sheath pulling will be a classic example – we documented that we were checking the pulses on the patient’s feet every five minutes while at the same time documenting that we were holding pressure with both hands on the groin.
If the patient is nice, holding pressure on their groin for fifteen minutes to stop them from exsanguinating (bleeding out), provides a good opportunity to chat. Most of the patients were focused on getting out of the hospital as soon as possible, so jokes about how they could always stay for the night if they wanted usually went over well. Once I joked like this with a male patient in his early 70’s and his wife. The joke fell flat, but it started a conversation. He had been hospitalized after a cardiac procedure (I do not remember what) and had had a rough time over several months. “It took us a full year to get the sore on his bottom healed,” said his wife. It had been all the way to the bone. Still I was thinking that he was lucky in a relative way. He had returned to his normal life in the end. The odds must have been against him.
But that was just the beginning. His wife began to tell me the story of her bypass (or “cabbage” as we say on the inside –CABG coronary artery bypass graft). There had been a bad batch of heparin or something and of four patients that were operated on that day; she was the only one who had survived. The others had died slowly over months, losing limbs piece by piece on the way. She had lost only one and a half fingers in the end. The doctors had told her never to let anyone give her heparin again. Her face and voice were calm and only a little weary and sad. She held out her hand for a moment to show her missing fingers and I noticed also a metal allergy bracelet. I looked at her face again. Her eyes were big. She was shaking like a leaf.
About a third of the patients had had heart transplants. These patients get a heart biopsy every week for the first 6 months or so after transplantation. It was a refreshing change to see so many healthy transplant patients leading essentially normal lives, a few of them even ten years out form transplantation. There were also some whose transplants had started to go bad. While still in good health, their terror could be compared to that of a person who has jumped out of an airplane to find the parachute will not open. You cannot get back to the plane and your old heart is in the garbage heap.
The biopsy patients did not need IVs – the tiny pieces of heart muscle were collected with a straight shot down the jugular to the heart. The procedure was simple and low risk and did not require sedation. The patients could come in at 7:30 am and be home by noon if everything went well.
The rest of the patients needed IVs, which gave me the opportunity to brush up on one of my weaker and least favorite nursing skills. I like putting them in about as much as the patients like getting them. Subsequently I have not become very good at it and that does not help matters. For two months I tried for as many as I could and I did get better at it, although Jay (a hard stick) would probably still be better served to ask for someone else.
Recovering the patients was all about pulling out “sheaths” (large bore ‘IVs’ that protect the blood vessels when the catheters are passed through) from necks and groins. One day I may do a post about the built in discrepancies between what is done and what is documented. Sheath pulling will be a classic example – we documented that we were checking the pulses on the patient’s feet every five minutes while at the same time documenting that we were holding pressure with both hands on the groin.
If the patient is nice, holding pressure on their groin for fifteen minutes to stop them from exsanguinating (bleeding out), provides a good opportunity to chat. Most of the patients were focused on getting out of the hospital as soon as possible, so jokes about how they could always stay for the night if they wanted usually went over well. Once I joked like this with a male patient in his early 70’s and his wife. The joke fell flat, but it started a conversation. He had been hospitalized after a cardiac procedure (I do not remember what) and had had a rough time over several months. “It took us a full year to get the sore on his bottom healed,” said his wife. It had been all the way to the bone. Still I was thinking that he was lucky in a relative way. He had returned to his normal life in the end. The odds must have been against him.
But that was just the beginning. His wife began to tell me the story of her bypass (or “cabbage” as we say on the inside –CABG coronary artery bypass graft). There had been a bad batch of heparin or something and of four patients that were operated on that day; she was the only one who had survived. The others had died slowly over months, losing limbs piece by piece on the way. She had lost only one and a half fingers in the end. The doctors had told her never to let anyone give her heparin again. Her face and voice were calm and only a little weary and sad. She held out her hand for a moment to show her missing fingers and I noticed also a metal allergy bracelet. I looked at her face again. Her eyes were big. She was shaking like a leaf.
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