Solid Gold

I had an elderly female patient in PACU yesterday, who had just gotten a knee replacement. As she was being hooked up to the PACU monitors, her gown got a little sideways, briefly exposing her nether regions. We immediately covered her with a warm blanket as she burst out laughing. "Girls" she cackled "you best not show that to the crowd. It'll blind them. It is solid gold!"

Good Times

I was floated to the floor this week. This rarely happens, as I am an ER, Preop, and Recovery nurse with little floor experience. However, desperate times call for desperate measures, I guess, so off I went to take care of some inpatients.
A gentleman in his 80's a couple days out from neck surgery was having trouble urinating. I got an order to straight cath him, which I did. He put out about a liter of urine and was much more comfortable afterwards.
I returned a while later, asking him how he was doing. he informed me that he had been able to urinate on his own.
"Are you having burning when you urinate, Sir?" I asked him.
"No, Maam," he replied "and I can tell you I don't have VD."
"Well, that's good to know," I said
"But you know I had the clap once" he started reminiscing, smiling dreamily. "Actually I had it twice when I was in the army. Back in Japan, you know. Goop just started dripping everywhere. Come to think of it, I recall I had the clap three times. Those were some good times, I tell ya" .

Taking Notes

I was working in Preop Holding the other day when another nurse emerged from one of the rooms with a large spiral notebook in her hand. "Someone left this behind" she said. We decided we would try to reunite the notebook with its owner later, but also noticed that the notebook was opened to a page filled with scribbled notes on the patient's care. I'm not sure why the note taker wrote all this stuff down. To understand the care of their loved one? For ammunition in future lawsuits? Who knows. But it was pretty interesting. The notes went like this, spelling and all:

Socks on bed  nightgown on bed  plastick bag on bed Put clothes in plastick bag
Sine paper
Start hose in hand
Lactade Richard's in hose
Vankamyson 4 Mercer in hose
U want warm blankit   6 minutes to get warm blankit
Nurse won't let u drink water
Tony come to sit with us
Tony want warm blankit   8 minutes to get warm blankit
Nurse won't let u chew gum
Anastisiologist talks to us say u will get pain med
6 minutes to get pain meds fetanil
Dr come to room to rite on arm
U ask if u can get fed meal after   Dr say yes
Nurse come to take cpap to recuvery room for after
Lisa and Michelle come to sit with us want to take some more socks home
Ask for more fetanil nurse say she cant give u more
U go to your sergery
*******************************************************************


Was it Chili's or Applebees that used to have the timers at tableside where if your meal was not delivered in 30 minutes, it was free? I guess this person had the same concept in mind.

Mercy or Murder? Who Decides?

As I have mentioned in the past, whenever I work in Preop Holding, something strange or confusing seems to happen. One night last week it involved a hip repair on a 90 year old. Hip repairs or pinnings are something we see everyday, typically in elderly patients after a fall. However, this particular situation brought some very strong opinions out into the open.

Anyway, a couple hours before the scheduled surgery, I called the patient's floor nurse for a report.  Instead of reciting the usual vital signs and statistics, the nurse stated that she was unable to give me report. She told me that the patient's daughter refused to give consent for the operation and had just left to go home.  The floor nurse explained to me that the patient had advanced Alzheimer's and was therefore unable to give informed consent and all that legality nonsense. 

So, since I've been in Surgical Services awhile now, I immediately understood what was the most pressing concern here. Thus I let the OR charge nurse know the situation, so that the surgeon would not be kept waiting. Surgeons, I have learned through various tirades, really, really do not like to be kept waiting.  So now that I had my priorities straight, I could move on to other things, such as maybe finally getting to pee nine hours into my shift. But that was not to be. The orthopedic surgeon in question, with resident in tow, came storming into the unit, demanding answers that I did not have. I had gotten the daughter's phone number from the floor nurse, so I handed it to him and suggested he call her. Before he made the call, he ranted for a while about how the patient was being sentenced to death by her daughter, the patient would be dead within a week without the surgery, that this was the most ridiculous situation he'd ever encountered in his twenty years as a surgeon, etc, etc. His face beet red with fury, the surgeon stomped out of the room to call the patient's daughter.

The resident, left behind by his leader, was muttering about euthanasia being illegal while he checked his Facebook. I went into the OR office for an update. The OR team for the hip repair was enjoying their unexpected leisure time in the office, along with another team in between cases. All were loudly vocalizing their opinions on the daughter's decision, which had ignited a fiery debate on the meaning of suffering and end of life care.

"It's murder" said one nurse "I heard someone was gonna call the police and have the daughter arrested"
"She just doesn't want her Mom to suffer more" said a scrub tech "we all talk about people being kept alive for too long. The daughter is doing the right thing"
"She'll suffer more if she doesn't get her hip fixed" chimed in the resident, who had gotten lonely and wandered into the office, still looking at his Facebook.
"I'm with the daughter. I wouldn't want to live if I was bedridden with Alzheimer's" asserted the charge nurse, a twenty year OR veteran "I put my dog to sleep when he was eleven years old and needed a second knee replacement. I didn't want him to go through that. Why don't humans get that right?"
"This is not a dog. It's a human being. Hellooo! I think the daughter is no better than a murderer. She's cold" said a scrub tech.
"Check it out" said a nurse "this is how healthcare rationing is going to start. You know...the death panels. The elderly won't be able to get surgery anymore. They'll just have to die"

 At this point I went back to my little area of the hospital and started preparing the charts for the next day...no paperless system here yet! Soon the orthopedic surgeon came back, and the resident stopped playing on his iPhone and started paying attention.  The surgeon explained that he had managed to make the daughter feel guilty enough that she okayed the operation for her Mom. He told me to get the patient downstairs ASAP and "Chop, chop". Yes, he actually said chop, chop.

We sent for the patient. I called the daughter to obtain a telephone consent. When I spoke with her, she impressed me as a caring, kind person. She was friendly and cooperative on the phone. Another nurse and I witnessed the consent. Then the daughter spoke with the anesthesiologist to agree to rescind the DNR order during the surgery. It was done in less than ten minutes. The patient was prepped and whisked off to the OR within twenty.

The patient had been unable to speak, but groaned and lashed out with her arms when I got her vital signs and hooked her up to some fluids. She got extremely agitated when I pulled TED hose onto her nonoperative leg. She did not seem oriented in any way.

I had mixed feelings about the whole situation. It is too rare that a family has actually discussed the patient's wishes before illness either creeps up slowly or slices into their lives with devastating suddenness. I have witnessed these talks only a couple of times, but felt privileged to see them. It takes courage and love to bring this stuff up. It is so much easier to live in denial, not wanting to think about our loved one being weak or ill, much less close to death. Declining a vent or feeding tube strikes me as a very common sense option when a loved one is terminally ill and unaware of their own identity or situation. Declining a hip repair, I'm not as sure. On a 90 year old with advanced dementia, maybe that's reasonable. But love and fear of loss can make it hard to think logically. I don't know what I would do if that were my parent. What would you do?

I'm sure as budgets are cut and healthcare costs continue to rise, money will also become more of an issue in these decisons. Studies have shown that a huge proportion of healthcare dollars are spent on end of life care, often prolonging lives by only days, and not happy days either. I think there are certainly many times that hospice is a better option than aggressive, invasive medicine. Often these patients are vented in the ICU  while their families are hoping the next, newest miracle drug or treatment will fix them. A 90 year old is one matter. What if the dying patient is a child?  It is heartbreaking for all concerned. I know it is incredibly hard to let go, but unfortunately as the money dries up, the healthcare systems may start making that choice for us.

We see patients on a daily basis with tubes in every orifice, decubitus ulcers, and a grim prognosis. We meet families who want everything done, rib fracturing chest compressions, tube feedings, rectal tubes, endless blood and platelet transfusions, every antibiotic under the sun, painful, but futile treatments to add a little more time to a life whose quality has declined to almost nothing. We grumble about how we want DNR tattooed on our bodies and sigh as we carry out the family's wishes.

Self Diagnosis

When asked if he understood the the procedure he was getting (repair of prolapsed rectum), the patient responded:

"All's I know is that they better be fixing my a$$. My a$$hole keeps falling out, you know."

Piano Students and Astronauts

   I had the pleasure right before Christmas of going to my two daughters' first piano recital. They hadn't been taking lessons long. I had just picked up our $250 piano off Craig's List in October, so they were still newbies. A large audience of parents and friends watched as kids ranging in age from roughly 5 to 15 with various skill levels approached the stage in the modest, old church and sat down to play their music. Towards the end of the recital, a student named Shirley was announced. I thought "Shirley... Hmmm you don't see many kids named Shirley these days". It turned out Shirley was in fact not a kid. Shirley looked to be at least well into her 50's and she played a beginner/early intermediate piece very nicely. I noticed some of the audience members kind of smirked at the older student. However, as I thought back on the recital later that night, I realized that I was pretty impressed. It takes courage and initiative to learn a new skill as an adult, especially in front of an audience.
   A little over a year ago when I was still working in the ER, I had a patient on New Year's Eve who had been hurt badly in a fall. She was a local college student who, while attempting to climb from one 3rd floor balcony to another in the dorms (apparently a common activity), fell onto the concrete below. She had not been drinking, later confirmed with a negative serum ETOH. We'll call her Jane. Jane had multiple fractures in her left arm and left lower leg. Her head CT amazingly showed no damage. She had several lacerations, only one of which needed suturing. Her vital signs were stable. An orthopedic surgeon was called in to fix her fractures up. A general surgeon was to evaluate her as well for any possible internal injuries. My other patients were all waiting on rooms at that time, so I actually had a chance to talk to Jane and get to know her a little bit while she waited for the OR. She told me that she was in the Navy ROTC at the college. She wanted to be a fighter pilot and maybe even an astronaut. She was concerned because she said the orthopedic surgeon wanted to fix her limbs with metal hardware and apparently fighter pilots can't have metal in their bodies. She told me that the surgeon mentioned she may be able to get the hardware removed at a later date, so that she could be eligible to be a pilot. Soon she was whisked off to Preop and the OR. The last I heard of her she was going back into surgery for a lacerated spleen and then up to the ICU. With all the orthopedic surgery and the possibility of a splenectomy, I assumed her dream of being a Navy pilot and astronaut was over.
   Fast forward to this past week. I was in Phase II Recovery with one other nurse. I had just discharged a patient and was tidying up the bay. Through the curtain I could hear a conversation between the nurse next to me and her patient, who was getting ready to be discharged. As I was listening to them talk, I realized the patient was Jane. I mean how many young female patients do we get who had a bad accident and want to be Navy pilots? At my hospital at least, not that many. I peeked around the curtain, and there was Jane. I introduced myself. Of course she did not remember me...I had given her a fair amount of morphine in the ER. She told me that she had been in surgery that day to remove the last of the hardware in her body. She was eligible to meet the physical requirements to pursue her dream career. The general surgeon had been able to repair her spleen without removing it. She was currently training for a 5k. Unbelievable.
    Now bear with me here...I know a middle aged woman learning how to play the piano and a college senior wanting to join the Navy don't seem to have a lot in common. However, these women both struck me as being very courageous in their own ways. They were not content with simply maintaining their status quo. I'm over in my little corner of the world wondering if I should go back for my long overdue BSN or if it's too late, too hard, too expensive, etc. When I look at Shirley and Jane, I wish I were more like them. I want to go out on a limb, but am scared to venture out of my treehouse.

Do Unto Others...

   The other night I was in Phase 2 Recovery. This is typically a piece of cake gig, a short stopover before the patient gets to go home. It is kind of like working Fast Track in the ER, all about moving patients in and out as quickly and as happily as possible. You only get stable patients from the main Recovery Room, or with some minor procedures, straight from the OR. Phase 2 has recliners, warm blankets, and yummy stuff to drink. It even has a fancy menu, ie. saltines, graham crackers, and broth. Each small bay has a chair for a family member to sit and visit with the patient until it is time to go home, typically after 30 minutes to an hour or so.
   I was breaking down a chart when I heard some commotion from the other side of the room. A very experienced Recovery nurse was telling a new nurse she was going to call the doctor "right now". I walked over to see if they needed help. The patient was on a stretcher. He was a male in his 40's, vacantly staring into space. I tried calling his name and doing a sternal rub with no response. We got him on the cardiac monitor and pulse ox. He had loud, irregular, snore like respirations. I attempted a head tilt chin lift to open up his airway more. His neck and jaw were stiff and uncompliant. I noticed his sheets were soaked through with urine. A CNRA arrived, inserted a nasal trumpet and started to bag him. I got the code cart. The Anesthesiologist got there and had me give the patient an amp of Narcan with still no response. The code team burst into the room and got to work. The Intensivist and the Anesthesiologist conferred on the situation. The patient's pulse was getting fainter and fainter. The Nurse Manager walked into the bay and informed me that I was going to need to take care of the patient's crying wife.
   Holy crap. In the ER we had patient reps who sat with family members. On day shift we had chaplains.  I looked at this pale, scared woman and thought that I would rather do a thousand chest compressions than try to comfort her. So, I walked over and put an arm around her, leading her out of the crowd gathered around her husband.
   I felt completely helpless and inept. She was crying and asking me if he was going to be okay. All I could say was that the team was doing all that they could. We prayed together. We talked about how they had met. She kept repeating "I can't lose him. I can't lose him". I held her hands, and we prayed some more. I could hear them starting chest compressions. I heard someone talking about PEA and V-tach. I heard the distinct sound of a defibrillator charging. When she heard a doctor yelling "Clear", her face drained of all color and she ran back to the bay with me in tow. One of the doctors present told me to get her into another room. Not everyone in the hospital is on board with family presence at codes.
   This woman obviously loved her husband very much and started to become agitated when she was advised to step out of the area. Right at this time Dr. J walked in. He was a partner of the surgeon who performed this patient's very minor procedure. Dr. J  was on his way to Preop to see a hip fracture patient. He immediately took in the situation and acted quickly with no hesitation. He could have just passed through with no comment as another partner had done. However, he headed straight for the patient's wife. Doctor J took her hand and introduced himself. He explained to her in simple terms what the team was doing and why. He sat with her for several minutes while she cried on his shoulder. He escorted her to her husband's side when the intensivist was about to call the code. She sobbed and cried for her husband to come back to her. Doctor J held her hand and then brought her back to me when he had to leave for the hip surgery.
   The patient's wife retreated to a private room to make phone calls, with me and her husband's surgeon occasionally checking on her. The actual surgeon was deeply shaken, stating he had never lost a patient before. The anesthesiologist who had been the first doctor on the scene looked devastated. He asked me if the wife knew that they had done absolutely everything they could. The patient's wife came out briefly to let us know that she was declining to pursue an autopsy, that she wanted her husband's body "left alone". She told us that her son was on his way to get her and take her home.
    Dr. J returned to the area briefly after a very quick hip pinning. He went with the wife to see her husband's body one last time before she left the hospital. Some staff were complaining that before he took her over to see her husband, Dr. J had removed the endotracheal tube from the body. However, since no one, including the Medical Examiner, wanted an autopsy, I guess maybe it didn't really matter. I believe that he was trying to make the situation easier for her to bear. An et tube can be a jarring sight when protruding from the mouth of someone you love.
   When the adult son arrived, the patient's wife gathered her things. She asked us to make sure her husband had a blanket, that he hated being cold.
    I said goodbye with a hug and a "God bless you".
   The next evening I saw Dr. J again. I thanked him for his help and told him that for a surgeon, he was a pretty good guy. He appeared genuinely perplexed by this and asked why. When I explained how much his involvement had meant to the patient's wife, he still looked puzzled. He stated "It's what I would want someone to do for me". I smiled and thanked him again before he left for the night.

Hugs And Kleenex

When I was working as an ER Tech during nursing school, I had the pleasure of meeting a great nurse named Johnny. Johnny had immigrated from Laos as a child and had a great perspective on life. The night I met him we were struggling with an elderly lady who had a severe reaction to Phenergan. She was post fall and having nausea, so the Dr gave her Phenergan, which immediately made her totally crazy and extremely strong. My job was to take the combative patient to CT, put on a lead apron, and make sure she stayed still for the scan. In addition, I was charged with keeping her grown daughter calm. Johnny watched me and talked to me about it during a smoke break: he smoked and I listened to him talk. He said that he could train a chimpanzee to put in a Foley or start an IV, but compassion was not so easily taught. He told me he thought I would make a good nurse, precious words for a nursing student discouraged by intimidating professors.
At times I think compassion is underrated, sometimes even disdained. Nurses can often be sarcastic and snarky when we talk about supporting patients emotionally or bonding with patients. I've gotten the "Well...I wish I had time to just sit and listen to patients talk, but I'm busy actually giving care" from other nurses, as if all I do is sit around and chat and neglect my other duties. We are of course encouraged to be nice and empathetic in nursing school, but also to keep a professional distance. As NurseXY mentioned in a recent blog, this professional distance is taught early on in order to ensure that our decision making abilities are not clouded by our closeness to the patient. I can see the point, but I think, as he wrote as well,  for many nurses it is sometimes impossible not to get emotionally close to a patient, especially if you are dealing with them in a setting where they are with you for weeks or months.
I have worked in ER, Preop, and PACU, places where we are with patients for a matter of hours, not days. However, we are with them at such a vulnerable time, where emotions are heightened considerably. We have interactions that I will certainly never forget.
Just this past Friday I was present when an elderly woman had a conversation with her daughter, son, and pastor debating whether to have surgery or if it was time to just stop fighting. All I did was provide the Kleenex and some hugs, but it was a privilege to witness the love and strength of this family.
That same day I took care of a man who came directly from his family doctor's office to the hospital to have major stomach and colon surgery, definitely not how he had been planning to spend his day. He was keeping up a stoic appearance. His wife walked over to the side of the room to use her phone to notify family members of the situation. I noticed that she had stepped over to the entrance of the unit to where the curtains were blocking her from her husband's sight. She was quietly crying. I went to her with Kleenex (again). She told me that she was just in shock and could not imagine losing her husband. I hugged her and just listened. It is an honor to help hold people up in their time of crisis and need. I am in awe of the fortitude of so many of these patients and their families. If I can provide just a tiny bit of support, just a little bit of warmth to help fuel them through this incredibly challenging time, I am privileged beyond belief.

Dr. Handsome Throws Another Fit

I had hoped that Dr. Handsome's tantrum, about which I wrote earlier, would turn out to be a rare occasion, a brief moment of temper not to be repeated anytime soon. Yeah, I was wrong. The last time I had encountered the pretty to look at Dr. Handsome had been in Recovery. This time it was in Preop. He had a patient with a hip fracture, a gentleman in his 80's. The patient was on an Amiodarone drip and had pacer pads on. His telemetry nurse walked down with him, which typically only the ICU nurses do. This guy obviously had some cardiac issues. Dr. Handsome had requested a Cardiologist consult for cardiac clearance, covering everyone's butts if this guy had problems during surgery. Well, apparently the Cardiologist's report was too ambiguous for Dr. Handsome. It simply stated that the patient was a surgical risk. He threw down the chart with a clatter and started raising all kinds of hell at any nurse within his visual range. He demanded that a nurse get the Cardiologist on the phone, so we did. The Cardiologist seemed genuinely befuddled by the conflict. Finally Dr. Handsome had to get on the phone and ask for a more specific endorsement of the patient's suitability for surgery. His voice and manner did get slightly nicer while he spoke with the other doctor. Dr. Handsome then ordered that a nurse get on the phone and write down word for word the cardiologist's statement because of course he could not lower himself to write them down himself. So I wrote down. "Patient is cleared for surgery however presents significant cardiac risks". Apparently this satisfied Dr. Handsome's cover his butt instincts. He examined the order sheet (I guess just in case I had mischievously written down something different), threw down the chart AGAIN, and stalked off to the mysterious realm of the surgeons' lounge. The patient made it through the surgery.

A Pain in the Butt

"As soon as I leave here I'm going to St. XYZ's ER. If they tell me something different, I'm gonna sue. I'm on Medicaid so I can go to every ER in this city if I want to".

-My ER patient, who was told that his hemorrhoid did not require immediate surgery, but was instead advised to try a 2 week regimen of topical ointment and sitz baths before a follow up appointment with the general surgeon.