Sunday, July 18, 2010

How to deliver bad news (not)

“If we had been doing our post-op neuro-checks like we are supposed to we might have caught it and been able to do something about it. Maybe we should look into that one day,” says the charge nurse a little wistfully and a little sadly. The next moment she is off to something else. This is my first time floating to the cardiac surgery intensive care unit (CSICU) and it is the busiest unit I have seen. My patient, Mrs. Jones, otherwise healthy for a 73 year old, has had a surgical repair of an abdominal aortic aneurism. During the operation blood flow to her spine was accidentally interrupted and Mrs. Jones is now a paraplegic, although she does not know it yet.

My other patient, Mrs. Smith, is on no less than six vasoactive drips, has a Swann (a pressure monitoring catheter that runs through the heart), is going in and out of V-tach and is already hooked up to the defibrillator in case she needs to be shocked at short notice. It is unusual to be assigned a patient in this condition on a first float to a unit, but she is awake and responsive and more or less stable. Given the level of acuity on the unit (the patients here are very sick) the assignment is appropriate. Tina, the charge nurse is very responsive, so I do not worry so much about the drips I am unfamiliar with and the Swann. I ask the questions I need to and get answers. When I arrived at this hospital, I received a four week orientation before I was allowed to take care of patients – and I had been working in the same kind of unit prior to coming here. Now I am floating, so I just have to say a little prayer and dive in.

Mrs. Jones’ daughter and son-in-law know about what has happened. They are waiting for the doctor to tell her himself before they talk about it with her. They are understandably impatient for this to happen. Mrs. Jones is lethargic, but awake, and asks occasionally why she cannot feel her feet. Her daughter responds by changing the subject. I try to find a doctor to speak with her, but the doctors on the unit all decline. They say that the doctor who did the surgery should be the one to tell her, and since he is in surgery now, he is not available. Mrs. Jones will have to wait. I explain the situation to the family.

I watch Tina following the physicians on rounds and coordinating the care on the unit. She seems twice the nurse I am. Her phone rings every five minutes with new information about patients coming to and gong from the unit etc. and she rushes all around the unit taking care of whatever needs attention. I do not have to wait more than five minutes for her to come around if I have a question. During brief pauses, Tina talks with her friend, another experienced nurse, about the stresses of being a single mother. After today’s twelve hour shift she has a PTA meeting. She wants to find a partner, but all the men are only interested in one thing etc.

Mrs. Smith’s Swann numbers and waveforms do not look right to me. Tina tells me to trouble shoot the setup, but I do not take Swanns very often, and what Tina is telling me to do does not seem to fit with what I am seeing on the monitor. I insist that Tina should come into Mrs. Smith’s room and look for herself. She does so and, after a minute or two of checking the tubing, she calls the doctor to advance the catheter. The end had been flapping around in her heart instead of being in the pulmonary artery where it belongs. No more V-tach.
Mrs. Jones’ family continues to wait in frustration. People from nutrition and physical therapy come by. Everyone wants her to know about her paraplegia, but we are all waiting for the doctor. The family begins to say that they will tell her themselves soon if the doctor does not come. I try to find out when he might be coming, but get no information.

The doctors order a blood filtration treatment for Mrs. Smith. It will be something like dialysis, but more simple. The treatment is administered by nursing. Tina wheels in a machine about the size of an average microwave oven and asks if I am ready to be trained how to use it. She leaves for a minute and returns with a plastic filtration cartridge. “Each one of these costs $3000,” she says as she rips open the sterile package. Tina begins the complicated process of inserting the cartridge into the machine. She gets confused and struggles with it for 20 minutes or so. While she is absorbed in figuring out the machine, her phone rings. A room is needed urgently for a new patient, but the only empty bed is being held for a patient who is in the OR. As she talks with the coordinator, she continues to work on the filtration machine and she forgets herself. “I wish X would just die in the OR (a hopeless case presumably) so that we would have the bed for Y.” I glance over at Mrs. Smith, but she is watching TV and not paying attention. Patients tend to tune out a lot of the discussions that go on around them as they are generally too technical to follow. Tina never did get the filtration machine set up.

A little while later I am sitting at the nurse’s station talking a little with Tina’s friend from earlier in the day. Tina comes by and I joke with her, “You know, it is usually not a good idea to wish one patient dead while in another patient’s room.” Tina turns pale and looks nauseous. “I do not think she heard you,” I add quickly. “I said that in a patient’s room?” Her friend starts to tease her about it lightly, but Tina does not see the humor in it. She is a good nurse.

Around 4:00 PM Mrs. Jones’ daughter tells me that they are ready to tell her about the situation if the doctors do not come right away. I let the doctors know and one of the fellows, not the original surgeon, comes to talk. He is obviously uncomfortable and unsure what to say. He explains that they are not really sure what has happened (lie), but that some blood flow to her spine was disturbed. They are not sure what her final status will be (lie). He tells her that the operation was very complicated and that she is lucky to be alive. He ends with “Just keep trying to move.” My anger rises as I listen. Why can't he tell her the truth so that she can understand it? As the fellow heads out of the room a technician from bed supply comes in. “Is this the New Para?” (as in paraplegic). This is now more than I can take. Will Mrs. Jones learn that she is paralyzed from bed supply? I ask the daughter for permission to clarify and she gives it readily. I tell Mrs. Jones that the blood supply to her spine was cut off during the operation and that the damage is irreversible. Mrs. Jones’ expression becomes so blank I become unsure if she can understand me. “Do you know what paraplegia is?” I ask. She nods once, still blank. “So, you are now paraplegic,” I say feeling how badly this is all coming out. I excuse myself as the bed tech starts to set up the specially padded bed which helps prevent bedsores from forming on immobile patients. I vent my frustration to the secretary, who alerts the nurse manager. She asks me about the situation and I tell her that I feel the fellow’s presentation was totally inadequate and ridiculous. I do not know what she did with the information, or what she thought about me or anything after that. We moved Mrs. Jones to the stepdown unit that afternoon.


risaden said...

glad to see you back in the saddle

Jay said...

Leo - finding your new post was my Christmas in July. Surely have missed your storytelling and the insight I gain from reading about your experiences. Wishing you all the best. Many thanks.

Barbalicious said...

I do not envy you. It takes a special person to become a nurse. God Bless