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.

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.

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.