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.

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

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.