Uh...Security Please?

Nursing is definitely a customer service based profession.  Nurses deal with people which can make it very frustrating, because people can be very difficult to handle at times. 

In my experience as a nurse, one of the many areas of healthcare that needs vast improvement is communication skills.  This is an important skill that all healthcare professionals should possess, however many times patients/family members are left wondering if there are any communication skills present in the healthcare profession. 

As part of my job as resource RN, it is my responsibility to handle any customer service issues that may arise on my shift.  I’m going to be honest and say that I HATE this part of the job and would much rather be able to hand it off to someone else.  Unfortunately that is not an option. 

A few nights ago, I was called to one of the wings by a nurse who was having a problem with a patient’s wife, daughter and son.  When I arrived, the nurse informed me the family was upset because they were under the assumption that the patient was going to have surgery that evening and it was getting late and they were curious as to why he had not left for the OR.   As the nurse continued explaining the situation it became clear, the plan of care did not include surgery of any sort, rather the patient was going to be discharged as soon as possible and evaluated at the outpatient clinic. 

As the nurse was explaining this to me, we heard yelling and screaming coming from down the hall.  As we went to investigate we found this particular patient’s family carrying on about the plan of care.  They were irate and yelling at everyone who crossed their path.  Now there are many problems with this situation.  First this patient was in a semi-private room, meaning there was another patient being exposed to the angry tyrant.  Second it was the middle of the night and the rest of the patients were trying to sleep, trying being the key word at this point.  And thirdly, the patient in question was lying in bed with a stressed out look on his face.  He was trying to calm his family down with no success.  As the family continued yelling, the patient began to look sicker and sicker.  Upon checking his vital signs, it was discovered his blood pressure was 210/267, which is extremely high.  At this point, this had become a patient safety issue and the situation needed to be handled. 

We tried to talk with the family members, but there was no calming them down.  We paged doctors on call and they came up to discuss the plan of care with the family.  This just resulted in the daughter storming out of the patient room, and entering the waiting room, where she began to throw around the coffee cups and coffee packets.  At this point, I realized there was really nothing I could do to diffuse the situation and had only one option.  So I paged security and asked them to escort the family out of the hospital. 

Security arrived and told the family to take it outside.  This resulted in one last loud and abusive tantrum before security removed them.  As soon as the family left the floor, a sense of quiet entered the wing once again.  The patient distressed rather quickly and his blood pressure returned to normal.  He was able to get some rest and by the time his family returned a few hours later, they had calmed down and was able to talk about the plan of care with clear heads.   As it turned out the problem resulted from one team of doctors telling the patient/family they were going to do surgery before discussing their decision with his primary team who had decided surgery was out of the question.  If there had been just a little bit of communication between these members of the healthcare team, this situation could have been averted and my night would have been a lot quieter.

Where has the dignity of death gone?

Its been three years since I graduated from nursing school and began working in a med-surg Acute care unit in a large academic hospital.  During an ACLS class, a nurse gave a presentation on the various kinds of strokes.  Noting the difference between supratentorial and infratentorial strokes-the former being more survivable and the latter having a more severe effect on the body's basi functions such as breathing-she said that if she were going to have a stroke, she knew which type she would prefer.  "I would want to have an infratentorial stroke.  Because I don't even want to make it to the hospital."
She wasn't kidding, and after working in a hospital for this long, I understand why.  Something else I emphasize with are the nurses who voice their advocacy for natural death-and their fear of ending up like some of our patients, in regular discussions of plans for DNR tattoos.  For example: "I am going to tattoo DO NOT RESUSCITATE across my chest.  No, across my face, because they won't take my gown off.  I am going to tattoo DO NOT INTUBATE above my lip."
One of my friends and co-nurses says that instead of DNR, shes going to be DNA.  Do Not Admit.  We know that such plainly stated wishes would never be honored.  Medical personnel are bound by legal documents and orders, and the DNR tattoo is at most just a very dark joke.
But I know of a nurse who has instructed her children never to call 911 for her, and readily discusses her wishes (or suicide pact as she calls it) with her husband.  You will never find a group less in favor of automatically aggressive, invasive medical care than nurses, because we see the pointless suffering it often causes patients and their families. 
I cared for a woman in her late 90's whose family had considered making her a DNR but decided against it.  After a relatively minor stroke that left her awake but not lucid, she went into kidney failure and started on hemodialysis.  Because she kept pulling out her IV lines and the feeding tube we had dropped into her nose and down into her stomach, we put boxing glove-like pillow mitts on her hands. 
When I approached with her medicine, she batted at me with her gloves, saying, "NO, STOP!"  She frowned, shook her head and then her fist/glove at me.  Her wishes were pretty clear, but technically she was "confused", because when I asked her name, the date and location she failed to give me the correct answer.
During the next shift, her heart stopped beating.  But despite the "professional arguing" among her medical care-givers about her advanced age and poor state of her health, her family had nonetheless decided that we should do "everything we possibly can" for her, and so she died in a frenzy of nurse's pumping her with vasopressors and doing chest compressions.  She spent the last few minutes of her life suffering with probably a few cracked ribs.
Another example, of a patient with advanced cancer, in this case an elderly woman with a well-informed husband who knew his wife was dying and that she didn't want to end her life with an extended hospital stay.
After her last tumor resection, this woman developed an infection, and during a meeting with her husband the attending doctor explained that he main problem we were immediately dealing with was the infection, which was bad and could well be something she would not recover from.
The patient's husband explained that he knew that his wife didn't want to be there and that her underlying diagnosis plainly meant that her life was going to end, that they both understood this and didn't want to painfully draw things out.  The he asked if he had any decisions to make, in effect being as blunt as he could without simply insisting that they withdraw care then and there.
The doctor said no.  She said that the patient needed to complete the antibiotics to see if the infection could be cured, after which they could approach the question of whether to continue with medical care.  So the husband's efforts went unheard and the patient ended up in the ICU, comatose, for two more weeks, quite the opposite of her stated wish, before everyone agreed to let her go.
Nurses love the opportunity to save a life.  It's why we chose our career, to help make a difference in someone's lives.  And yes there are occasions when this happens in the hospital, and it is exciting and miraculous.  But in the instances I've described, and many, many others, nobody involved is under the delusion that live is being saved.
The absurdity weighs me down, and so i want to describe it to you.  Medical science can do incredible things.  But you would not believe the type of life these life-sustaining treatments often allow.
People who are at the end of their life and are being kept alive artificially have a way of shutting down.  Fighting this process is not a peaceful act.
Most patients end up on ventilators, with plastic tubes pushed into their mouths and down their tracheas in order to provide respiratory support.  The tubes are taped to their faces, and patients who can move at all are usually both tied down by their arms and sedated when on a ventilator, because it is so physically uncomfortable that patients will use their last ounce of strength to pull the tube out of their mouth.
Intubated patients, and patients in comas are unable to clear their respiratory secretions and so we stick smaller rubber tubes connected to suction into the breathing tube, down their trachea and towards the entrance to the lungs themselves, in order to vacuum the secretions out of their lungs.  Only adding to their discomfort.
These patients obvisouly can't eat, so they will have had a feeding tube pushed up their nose or through their mouth and their esphogus, down into their stomach.  This often takes a few tries, requiring us to pull up the bloody tube, re-lube it and push it back in at a different angle.
If a patient is ill enough, these instruments will be replaced with a tracheostomy in the neck rather than a tube down the mouth and a feeding tube going directly into the stomach rather than down the nose.  These are for patients who aren't expected to be able to eat or breathe independently in the long term.
These patients often develop diarrhea, simply because of the liquid food they receive, cans of smelly, nutritionally balanced, tan-colored slush; and sometimes because they have acquired a very hardy and aggressive bacteria, C. diff that is widespread in hospitals and causes profuse, foul stool.  If they have diarrhea several times a day and their skin is exposed to it, the skin begans to break down, and so we place a rectal tube in their bottom, held in place beyond the rectum with small water filled balloon.
The diarrhea drains into a clear bag that hangs on the side of the bed. 
Breathing, feeding and rectal tubes are only part of it.  These patients also have catheters and IVs, often larger IVs that are placed centrally, threaded straight toward the heart to allow us to push drugs in concentrations that would damage smaller veins.
Healthier hospitalized patients complain sometimes about their IVs and frequently about their urinary catheter, a rubber tube up your urethra isn't pleasant.
You think all that sounds unpleasant and torturous, I haven't even had the opportunity to explain about the heparin injections.  We treat most patients with small shots of heparin in the subcutaneous flesh, in order to prevent blood clots.  This makes them bruise easily and many patients are often peppered with tiny bruises from the shots.
It's been said that dying is easy and it's living that's painful.  Not so in the world of healthcare as a patient.  Patients who have a hope of recovering from their injury, genuinely surviving it, may be fighting to live.  For them the torturous days as a patient are required in order to surmount their illness.  And there are always cases where nobody knows what the outcomes may be, where the right thing to do is maintain physical function and give the body time to heal.
But time and again we care for patients who are fighting to die, and having a very hard time of it, because in the hospital there are only two ways to die: with permission, too often not granted or granted too late, or in the last-ditch fury of a full code blue.
We are not helping these people by providing all this intensive care.  Instead, we are taking these people and turning their bodies into nothing more then grotesque containers, and reducing their lives to a set of numbers: monitoring input ant output, lab values and vital signs, which we tweak to keep within normal ranges by adjusting our treatments, during the weeks and days immediately preceding their death.  This the opposite of what should be prioritized when a person is known to be nearing the end of their life without the hope of getting well.  
Nursing is a difficult job, emotionally and physically, and many times we are made to question our work.  Many times we have to deal with feeling that our work is morally questionable and at times reprehensible.
Our goal is to help these people, and assuming that prolonging their lives for the longest time possible is the only way to do this is a foolish and harmful mistake.  We have forgotten that our patients need to have the choice to choose to die with dignity instead of wasting the last few days, hours and minutes of their life fighting for the right to die on their terms.  

When a nurse Says Goodbye

Just the other day, I was aked, "How do you sleep at night?" by the friend of a patient who was dying.  But I was not asked nicely.  I was asked very sarcastically, all because I was one of the participants in the bearer of bad news.  "There is nothing else we can do. Your loved one is going to die."

Nurses don't enjoy being the bad guy.  And we don't enjoy having to agree with the bad news just given to the loved ones of those dying.  The truth is, every one of us would love nothing more then to see you get that miracle you are praying for. But we would rather be the bearers of bad news than the encourager of false hopes.

We survive twelve hour shifts, often several of them in a row, with breaks only long enough for a drive home, a shower, and a nap before returning to care for very sick people all over again.  Exhausting! And not only physically, but emotionally as well. 

You see, we may leave our charting at work, but we bring our worries home with us.
"Did I miss anything?" Was there anything else I could have done for her today?" And at 2am (or 2 pm for those night shifters), when we wake up for a moment in the night, our thoughts immediately as we look at the clock return to your loved one..."Gosh, I wonder how she's doing right now."

We know every inch of our patients skin.  We know how they react to our touch, how they respond to each one of their family members, and know how they will respond to their medications.  We watch people go in and out of the rooms, and we very protectively question them..."Who are you? Did you need something?" Or to technicians who enter their rooms..."What are you doing with my patient?"  We turn them, tuck them in with soft pillows, rub their feet with lotion, cover them snuggly, reassure them, caress their forehead, and tell them it's going to be okay.

AND WE TELL THEM GOODBYE.

Often some of the most intimate moments are behind curtains with the door closed.  We really do care for your loved ones.  Nurses are people too.  We are mothers, daughters, sons, fathers, brothers, and sisters.  And we too, have lost loved ones.  We know what a breaking heart feels like, and when your loved one is dying, and we have had the privilege of caring for them...our heart gets another ache in it, and it often causes us to recall loved ones we miss dearly!

So we close the curtain.  We caress their forehead, we hold their hand.  We look them in the eye and say, "You did a good job.  You are a GOOD mom or dad! And your family is going to be okay! Yes, they are going to miss you, but they will be okay!"
WHAT A PRIVILEGE IT IS TO CARE FOR YOUR LOVED ONE...

I missed saying goodbye to the family member of my patient the other day, because I was off the floor when he left.  I so regret missing seeing him off, because he was so appreciative and kind.  I would have liked to say goodby.

So because I was unable to tell him...I'd like to tell anyone who has ever told a nurse that they appreciated her or him...here is what I would have told him...

"Thank you!!! Thanks for the honor of caring for your loved one.  Thank you for acknowledging me and not being angry at me because of the horrible prognosis we hated giving you.  Thank you for having the courage and strength to honor your loved one's wishes and letting them go with dignity, comfort and peace!"

"THANK YOU FOR TREATING ME KINDLY"

We nurses care for ALL of our patients, but sometimes, there are just some who we will never, ever forget.
And remember that very last "turn" with the curtain drawn and the door closed? That just might have been when we said our goodbye...

Two in One Night...Oh Come On!!!!

There are bad nights in the hospital, and then there are really bad nights.  Last night was a really bad night.  As I walked into the hospital and made it to the floor I work on, I heard over the loud speaker “Code Blue, Code Blue”.  This is not a good thing at all.  In fact it means that a patient is coding somewhere.  As I rounded the corner I found the excitement.  I jumped in with chest compressions and helping out wherever I could.  Unfortunately, the patient was too far gone and was not able to be saved.  Not a great way to start a shift.  This was going to be a very long night. 

As I was making my rounds, one of the nurses informed me of one of her patients that was not doing very well.  In the few minutes we had been there she had started to take a turn for the worse.  Her oxygen requirement had increased and she had to be placed on supplemental oxygen.  Her breathing had also increased and she was having trouble catching her breath.  We paged the doctor who ordered a chest X-ray and some medication, Lasix, to help pull any fluid off of her lungs.  However, he was not extremely worried about the patient’s condition. 

However as the night progressed, the patient respiratory status continued to decrease.  Her oxygen was increased again and again until she was requiring the highest amount of oxygen therapy we were able to provide on the floor.  She was still having trouble catching her breath, and after every breath she was having a weak cough.  In fact just by looking at the patient it was obvious she was exhausted and her energy to even take a breath was wearing out quickly. 

We re-paged the doctor, who came to the bedside to assess the patient.  He continued in his assumption that there was nothing wrong with the patient and he did not want to do anything at this time.  We paged Rapid Response and they came to access the patient and immediately knew something was wrong.  They managed to push the order through to get the patient moved to progressive care, however as our luck would have it there was no beds available at the time and it would be awhile before the patient could be transferred.  This turned out to be a very dangerous situation, because the patient was quickly approaching a point where she was not going to be able to breath at all on her own, which means we would have to call a code and the likelihood of reviving the patient would be slim.  However, if we could find a progressive bed for her they could move her and intubate her before it reached the point of a code.  Two hours later, a bed finally became available.  As Rapid Response began to move the bed to transfer the patient, she stopped breathing and they ended up taking her to the progressive floor doing chest compressions.  When they reached the new bed, they intubated the patient and she was able to get the oxygen her body demanded.  This was one work night I wished I would have called in for. 

What in the World is Going on With This Patient?

Sometimes one of the hardest things about nursing is knowing what is actually going on with a patient…especially in the middle of a patient decline.  During a decline, it is the responsibility of the nurse to inform other members of the healthcare team (doctors, rapid response, and respiratory therapists, etc.) what is happening with the patient.  The information obtained from the nurse helps set the treatment plan. 

However, many times when a patient is declining, there are a million reasons why the patient may not be doing well.  In fact many times, it is impossible to tell right away because so many different declines may have similar signs and symptoms, which may prolong diagnosis and treatment.

 
The other night was a regular, ordinary night with not much action occurring.  In fact we had all gotten into the mindset that this was going to be a good night, and this was our mistake number 1 (Never ever as a nurse or healthcare professional even entertain this idea, because as soon as you do, you will have jinxed yourself 
every time).

 As we were basking in our quiet night, one of the nursing techs came and informed us that one of the patients was acting a “little funny”.  She was definitely more confused and more agitated then she had been for the last few nights we had been there.  We went and checked on her, but found nothing to be alarmed about, our mistake number 2 (Never assume just because some patients get confused over night in the hospital, that this is normal for all patients).

 Twenty minutes after checking on this patient, I was giving some medications to another patient, when I heard patient number 1, start yelling at the top of her lungs.  “Help!!! Help me!!! I need you to help me right now!!!”  I went running into the room with the other nurse and we found the patient laying in the bed with a crazed look in her eyes and tossing herself all over the bed while still screaming at the top of her lungs.  Her next words got us springing into action.  “I think I am having another stroke!!! Help, Help me please.  I don’t want to die!!!”

 We quickly asked the tech to get a set of vital signs (temperature, heart rate, blood pressure, respiration and oxygen saturation).  While he was doing this, I quickly did a stroke assessment trying to ascertain whether she really was having a stroke.  My assessment came up inconclusive because there were some signs and symptoms of a stroke, but not enough to warrant a stroke alert.  The tech informed me he was not able to get a temperature on the patient.  I asked him if he would mind getting a blood glucose level.  Sometimes when a patient’s glucose level is low they tend to have signs and symptoms of a stroke.  As soon as the tech informed me of the glucose level of 15, I knew we had found the reason the patient was declining.

 I quickly ran out of the room to grab some D50, which is a concentrated form of sugar that is pushed into a patient’s IV to raise the glucose level in the blood.  However, as I ran back into the room with the D50, the other nurse, the patient’s nurse, informed me, “Oh shoot she doesn’t even have an IV.”

 Because of the no IV access, the treatment options had become very limited.  I quickly grabbed a glucose gel tube and some glucagon.  As the other nurse put the glucose gel under the patient’s tongue, hoping the sugar would absorb into her blood, I quickly mixed up the glucagon and administered it as a shot in her leg.  When we rechecked her glucose level again, it was 14.  Our mistake number 3.  (When you arrive for your shift and you learn that one of your patients does not have an IV, it may be a good idea to ensure an IV is placed BEFORE the patient actually begins to decline and every minute counts).

 While we were starting the IV and administering meds to help the patient, the patient was yelling the whole time.  She was saying she was dying, she knew it.  She was having a stroke and we needed to help her.  Finally I grabbed her hand and was able to calm her down with a quiet voice.  Within seconds of placing an IV we were able to administer the D50, and within minutes she was more responsive and aware of her surroundings.  Thankfully all the pieces of the puzzle fell into piece relatively easily for this particular patient decline and we were able to quickly provide treatment with no harm to the patient.  

I HATE these caps!!!!!

Many times the supplies or equipments we use in the hospital may change based on availability or cost.  The newest change to hit us has been our IV connectors and IV caps.  Now usually I don't notice a difference in most things, however, I am going to be completely honest and say I HATE these new connectors and caps.
I was in the middle of starting a ridiculously hard IV when I attached the cap (we didn't have any connectors at this time).  The IV was drawing blood beautifully, however when I went to flush it, it would not flush at all.  No matter what I did, I was not able to flush the IV, which meant that I had to take the IV out.  It frustrated me a little since I knew the IV was good since it was returning blood.  Anyway I found a new spot and put in a new IV.  This time when I placed the cap on it flushed and drew beautifully.  YAY!!!  I taped it all down and hooked up the fluids.  Of course as soon as the fluids were attached and turned on, it decided it didn't want to work (I was not happy about this, thinking I was going to have to change the whole IV yet again).  I retaped the IV and did everything I could think of to make the IV work, with no success.  I finally went to a different unit and found an IV connector.  After connecting the connector and starting the fluid, it again did not want to flush.  At this point I was beyond frustrated.  A task that should have taken 15 minutes was turning into a 45 minute job.  Finally I got the bright idea to replace the cap on the end of the connector.  As soon as this was done, the IV worked like it should have.  I was so happy that I did not have to change out the IV again, especially since the patient was needing some blood pressure meds for her BP of 220/113.  

I Kill You!!!!

Since I work in a big hospital, there are occasions when the patients we care for are prisoners from the surrounding areas.  Many times, people are scared to enter their rooms because they are afraid they will get hurt, however, I always think these are the safest patients because there are always at least one guard stationed in the room.  The patients that always make me a little paranoid are the patients who have a mental health issue.  There are no guards in their room, and many times, it is impossible to tell what they are thinking or about to do. 
One patient in particular this week has managed to make most of the staff members wish we did not have to enter his room at all.  He was admitted for osteomylitis in his spine secondary to a past gunshot wound.  From the minute he was admitted he was telling stories of his time in prison.  While making conversation he would expand that it was because he had killed his first man when he was 10 years old.  As he continued to talk his stories became more and more violent and graphic, until he reached the point he was threatening every person who entered into his room. 
Well of course I was the lucky person who got sent into draw some labs.  While I was doing this, he was screaming at me and threatening to throw me through the window.  It was quite fun.  Honestly, I got the impression he threatened everyone but would never really act on his threats.  He said he was going to bring a gun in and shoot everyone, he threatened to kill his doctors because they didn't know what they were doing, he threatened to kill the cleaning ladies because his room was never clean enough.  In fact I didn't really pay attention to most of the the threats.  However, that changed really fast. 
When I returned the next day, I was met with serious faces.  The day nurses informed me that the patient had physically threatened one of the staff members and was now a candidate for having a security officer stationed in the room with him.  However the patient could still go down to smoke unsupervised because of course we do not want to invade on his privacy (really! Honestly...how does this make any sense!!!!????).  During one of these trips down to smoke, we received a call from another security officer informing us that they were going to return the patient to us, and he was no longer allowed to leave the floor. Apparently this patient had physically grabbed a doctor in the hallway and was beating him when the officers showed up.  The reason "I don't like those foreign doctors."