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.

1 comment:

Anonymous said...

DRT--Dead Right There