Tuesday, May 23, 2006
Since I missed Grand Rounds last Tuesday(and actually missed Tuesday, last Tuesday, being out all night), I've included Dr. ibear's Grand Rounds here-which I'm still reading.
This week, check out Parallel Universe. Someone else is writing about donation for a change. I, meanwhile, am ranting about being a patient. Maybe that's why it's called Parallel Universe.
I hope Laughing Baby sleeps tonight, 'cause I've got a lot of catching up to do.
Saturday, May 20, 2006
Treat Me Like a Child
I noticed a few things while working as a pediatric nurse. Kids get treated differently. They get treated, well, like kids. They aren’t expected to behave, to sit still for shots or take nasty medicine without, at least, making a face. We give all kinds of consideration to young patients. We take our time with them. Treatment rooms are pretty standard, so painful procedures get done elsewhere and the patient’s room remains a safe place. Newer children’s hospitals put in diversions, like Play Stations and toys and books. They come in bright colors and have a Child Life Specialist to explain all the scary things and to see what makes the child happy and more secure during their hospital stay.
Recently, I visited a friend (a grown-up) on the oncology floor. I expected the treatment there to be a little more patient-friendly than the average floor because in many ways cancer patients get treated like children; they’re both considered “innocent victims” of disease. But my friend was considered “a good patient.” She was sick, but not too sick. She didn’t complain a lot. She tried to be upbeat and cheerful and helpful when called upon by nurses and doctors to do things that weren’t pleasant. She told me that she didn’t see her nurse a lot and when she did, it wasn’t for very long. “I guess she’s busy taking care of her sicker patients.” One doctor who promised to come in and check on her every day, came by once during her two-week stay. She found out different things from different staff as they paraded through her room each day. She was scared because there didn’t seem to be “a Plan.” It was like fitting together the pieces of a puzzle. She needed the advice of friends who were nurses and doctors to put it together for her, because the staff certainly didn’t. In the end, the things that satisfied her she got because she opened her mouth and complained until something was done. Why does it have to be that way?
So here is my patient manifest. A list of requests, (okay, demands) for my caregivers, should I find myself ill.
Don’t expect me act like a grown-up. Grown-ups get scared too, but don’t like to show it, so it may come out in different ways. They may have denial or anger, or they may be overly cheerful and helpful. Expect that underneath, I am scared. If I act like a grouch and snap and generally act hateful, don’t take it personally. Treat me gently. Certainly, you should give up on the idea of me being “the good patient.”
Think about where I am in my life. Erikson’s stages of development don’t stop when someone reaches the age of majority. When’s the last time you put down “Integrity vs. Despair” on a care plan? People have real, developmental needs throughout their life span and they shouldn’t be ignored by health care providers because they’re adults.
Explain things to me like a child. Not condescending-but simply. Avoid big words and ask me questions to see if “I got it.” Part of assessing the patient is to see how much they know about their condition and don’t take that for granted. Medicine and hospitals are foreign concepts to anyone who hasn’t been ill. Most people know more about how to maintain their cars than their bodies. Part of your job is to communicate. Please don’t tell me, “He’s a real jerk, but an excellent doctor.” I don’t care how well you diagnose, treat, cut, or cure. If you can’t communicate effectively, you’re not doing your job well.
If I’m well enough, give me something to keep me busy. We all know if you keep a child occupied, they’ll stay out of your hair for a while. And I don’t mean the TV. I hate walking into a hospital room and having that TV blaring 24/7. It’s not just a babysitter for kids anymore. What happened to daily rounds by a volunteer with a cart full of books, newspapers and other diversions? And God forbid if every hospital room doesn’t become private soon. Yes, roommates can be a bother, but it can also give you someone to talk to and commiserate with. I used to work on a floor that still had one four-bed room. More often than not, the four would become fast friends and you wouldn’t have to answer a call bell all day.
Let me have control over something, even if it’s little. I hate to feel like I’m just another number on the pill-dispensing assembly line. If I want to take my aspirin with lunch, let me take it with lunch. So what? If it’s something that can’t be changed, take the time to explain why to me (see #3).
Have a plan and let me, or my family, in on it. Floors should have walking rounds, with all the members of the healthcare team. Everyone knows what’s going on and everyone gets on the same page. Do it at the same time everyday so that I and my family can know when you’re coming and get the answers we need. I need to have my family or a close friend with me when you talk to me. Just like a child, I get overwhelmed with too much information and may need a second set of ears to hear what you’re saying.
Treat me like an “innocent victim” regardless of whether I’m in the hospital for cancer or a drug overdose. Many, many people are hospitalized due to their own action. Does it really matter if it’s because of too many beers or too many cheeseburgers? This is called compassion and it’s usually not thought of until it’s missing. You would think that some patients would be above judgment, but once I overheard a doctor say, “We’re going to harvest HIS organs? Why, so another drug addict can get a liver?” Give me a break.
It sounds simple enough, but it’s rarely seen. There are some good excuses, I suppose: managed care, high patient to nurse ratios, staff burn-out and many other issues that are better saved for another time. Even so, if I should ever find myself in a hospital, save a bed for me in PICU, I want to be treated like a child.
Here's a story from Malaysia about how a 19 year old donor inspired others to come forward and sign up as organ donors. They have a neat time line of events, showing how it all went down with the recovery(or harvest, as they apparently still say in Malaysia). We stopped using the word harvest because I guess it sounded a little harsh for the donor families, like we're going to reap some beans or something. One surgeon I talked to like harvest better because he thought it sounded more natural. Anyhoo, enjoy.
Friday, May 19, 2006
Just got this site from Our Friend Kim at Emergiblog. In the Unit. Besides the fact that she can write, the page is awesome! Who do I have to sleep with to get a website that cool? And yes, the pull down menu is totally cool. (Do I sound like a teenager, because, um, like, I think I do).
I did another 24 this week. This time with an orientee-Gosh, I can't believe they trust me to teach the new people(smirk). It was a great case for her, we did from soup to nuts(translation-ER to OR). And the unit we were on was very helpful. The staff did a great job of not just maintaining the patient, but also being supportive of this family. After consent they did everything we asked them-Aline, central line, meds, blood. It all went very smoothly.
The problem with being a TC is that it gets lonely. You're out there all by your own self and the staff not only doesn't know you, but they're busy and stuff. So you don' t really get that comraderie going. So, having another person around was great. Except that I felt like a new mom who hasn't been out of the house in a few weeks-I couldn't stop talking! "Ohyournewandwheredidyouworkbefore-andhowdoyoulikeithereandthisishowyoumanageadonor" Agh! Somebody stop me!
By the time we got to the OR in the wee hours of the morning, she had that deer in the headlights look. But she told me the next day that she thought it was a good first experience for her. She asked me how you get used to being up for 24+ hours in a row. I'm not really sure, but somehow I did. It's a long drive home in the morning though. Sometimes I pour cold water on my neck to stay awake. I'm pro donation, but not so much I want to actually want to cause my own head trauma.
Monday, May 15, 2006
All right, listen up. This is a seriously long post. So go to the bathroom, grab a snack, take the phone off the hook and tell the kids to be quiet. Don't say I didn't warn you.
Keifer Sutherland can kiss my butt. Last night I did a real 24, and I didn’t get to film it over a bazillion episodes, either. Here’s how it went: I got called out at 0615 to evaluate a potential donor who was unstable. 24 hours later I was leaving the hospital having completed a successful organ recovery. So what did I do in that time? Well, I don’t have fancy split-screen technology and multiple camera angles, but I think you’ll get the idea.
0615 Triage calls me to go see this patient. I have an hour to get on site, so I jump in the shower and get ready, only to find at
0700 My car won’t start. I left the lights on (Doh!!). I call triage back and let them know. Fortunately, another coworker is already en route to the hospital to help me out, so she’ll arrive first. I call the hospital and check on the patient’s condition. The nurse allows that he’ll keep the patient from coding ‘til I arrive.
0830 Finally arrive in Shoot’em Up City Medical Center. My patient has his brain injury the old-fashioned way, from a spontaneous bleed in the brain, but that’s rare in these parts. My coworker is already in the unit, watching the attending chew out a resident for not calling him in the middle of the night with a bad ABG result. This continues for some minutes. When the dust settles, we huddle and decide what the course of events is going to be the morning and how we’re going to manage the patient. I’m impressed with the doc right away-he really wants to help us keep organ function viable in this brain dead patient and do whatever he can to help us get consent. Ahhhh, when they don’t fight you at every turn. It makes my heart happy. Neurosurgery was in already and started the first brain death clinical
0915 Doc takes the family into the conference room to talk. When they can’t talk at the bedside, it’s usually bad. He comes back several minutes later and says that he told them the prognosis was brain death. They want to make the patient a DNR and remove the vent. If I’m going to ask them to make him an organ donor, it has to be now. Coworker and I head to the family room. They have already declined a priest or a counselor, so it will be just the two of us.
Conference Room-I introduce myself to the family as a nurse who works with families of patients with devastating head injuries. Sometimes I’ll have the doctor or nurse introduce me as part of the health care team, but today I just walk in for no other reason than my spidey senses tell me to. His parents are not English speaking, but a family member translates. I tell them that I know the doctor has given them some bad news and that I’m here to see if there’s anything they need and to help them make some end-of-life decisions. Mom says she knows he’s gone. They talk about having to make funeral arrangements and taking his body “home” (he’s From out of state). This is important. You can’t ask for organ donation is they think the patient is going to recover and walk out of the hospital some day. You can’t ask them the second you tell them about brain death-they need to absorb that information first and really process it and understand what it really means. If they’re saying, “well, the doctor says he has a one percent chance of making it,” or “will he be like that person on TV and be a vegetable for 15 years,” they’re not really understanding brain death and you need to do more teaching before you ask for organs. I mean, come on, it’s not brain surgery, and yet I’ve seen more than one brain surgeon say the stupidest things to family members. The family keeps talking back and forth in Spanish. All I pick up is “Corazon, something, something, corazon”. Finally, they say yes. They want other people to live, not that he’s gone. They just want the recovery done by tomorrow because they want the funeral arrangements made and to bring him home.
1030 I go over the consent with the family and the family member who speaks English does the medical-social history with me. It takes about 20-30 minutes, depending on how much history the person has. I like to tell people that it’s like the questionnaire you fill out when you donate blood. Some questions are very general, some are very intimate. I ask every family these questions, whether the donor was 5 or 95. So please don’t be offended. I’ll reiterate that right before we get to the question that asks if Grandpa ever had gay sex for money or drugs. Please don’t be offended. In more cases than you think, it’s actually an ice-breaker. People start laughing, “Oh, God, if he was only here, he’d be so mad!” or something like that.
1100 Everything’s being done at once. I draw blood for serologies and HLA testing. This takes about 8 hours to process, so we do it as soon as we can. I call triage, I call the office. Triage goes nuts because I promised this family that we’d do this by tonight. Never make a promise you can’t deliver. I’m not worried. We’ll get the second clinical at 1500-it’s already set up with the doctor who’s going to do it(the same one who was yelling at the residents, bless him). We’ll have serologies this evening and then go to the OR. I may even be home by 2am. That would be nice. I call home and tell LM the good news (or bad news, that I’ll be out all day). I’ll call later when I get a better idea what’s going on. LM wishes me luck. Coworker and I start working to get an echocardiogram done. Lungs will be out-he smoked 2 packs per day for 25 years and his PO2 is 75 on 100% FiO2. So, no good. Also, he’s starting to go into renal failure for no reason I immediately think of. His BUN/creatinine was 49 & 2.2 this morning. Now they’re 50 and 3.5. So I’ve got to try and reverse this. Or at least halt it.
1130-1430 I get the hospital to start a synthroid drip. The patient is on levophed and dopamine to keep his blood pressure up. The synthroid will make him more hemodynamically stable and hopefully we can come down off the other pressors and maybe save his kidneys. Meantime, the echo is done and lo and behold, a cardiac transplant surgeon is in this hospital seeing patients and reads it. Bad news, his hearts a mess. Left ventricular hypertrophy, pulmonary hypertension, right ventricular enlargement and an aortic valve stenosis. Finally, he has a small, pericardial effusion. Even I can tell his heart looks bad on the echo and I usually don’t see anything on a sonogram. We had the cath lab on standby but we call them and tell them it won’t be necessary. So, now we’re looking at recovering liver, pancreas, kidneys and tissue. He’s way ahead on fluid, so boluses aren’t really going to help. I ask them to give 5% albumin, 40mg lasix and another albumin to see if that helps his urine output. 2 hours later, still no pee.
1532 Patient is pronounced legally dead. The doctor goes out to tell the family in the waiting room. A large group of family comes in with their own priest and prays. Someone asks when they are going to take him off the machine. I had gone over this with the immediate family, telling them that he’ll be on the ventilator until we go to the OR, but now I’m wondering if maybe it got lost in the translation. So I get someone on staff to translate. They say they know, they’re just waiting for more family to arrive then they’re all going home. Meanwhile, I’m keeping up on my charting. We’ve called the OR to tell them we’ll be doing the recovery sometime tonight. The nurse manager stops by to see if we need anything. The attending comes over with the residents and tells me that if I need anything to just tell them. Then he tells them to listen to me. I like this guy.
1800 I’m making calls to transplant centers to share the organs. Serologies are back and they’re negative. Liver gets accepted right away by a local program. I keep making calls to find a backup in case they get to the OR and don’t like the way it looks. Someone actually is interested in the kidneys, despite the BUN/creatinine. OR says we can go at midnight, my recovering surgeon agrees. Woo hooo! I’m excited by the “early” OR. Usually we’re going at 0400. I start calling the tissue banks but because this guy had a history of drug use, no one wants his tissue-so no bones, heart valves, eyes, ligaments, skin.
2000 His urine output is still almost zero, despite my attempts to turn it around. I’ve talked to my medical director. We’re out of ideas. We’ll draw labs at 2100 and see what happens. I’m getting myself together, all the paperwork I’ll need for the OR. The recovery specialist has been called and will be here to help with the OR. My coworker goes home. I meet the night shift nurse and go over everything with him. So far, so good.
2130 Recovery surgeon calls. They have to move the OR back to 0200. Damn! OR says that’s fine with them. The anesthesiologist comes over and I give her our info sheet on what we need from her in the OR. I also have a pick list for the OR staff so they know what we need.
2215 Labs are back. BUN 52. Creatinine 4.5. Kidneys are out.
2330 I make sure everything is ready. My charting is done and ready to be copied and put in packs that go with the organs (organ, in this case). I grab something to eat. I ate once, earlier, about 1330, but I’m starving again. I try to not imbibe too much caffeine, it only backfires and makes me frazzled, so I’ve only had one cup of tea since this am. Do chocolates count? Cause I’ve had a few of those, too.
0030 Oh, the hour I should have been in the OR. I try and lay my head down and nap but I keep getting phone calls and pages.
0130 I run over to the OR to make sure they’re ready. They have a fresh pot of coffee, so I give in and have some. The nurse starts packing up the patient and we call respiratory for the ride over.
0230 Incision. The circulating nurse is, I actually believe, nuts. She’s certainly driving the scrub tech crazy. She asks a million questions, which is not so bad, but always at the wrong time. Then when I need her, she’s gone. My surgeon is cranky and so am I, having been up since 6am. We get the solutions set up for flushing and storing the liver.
0323 Cross clamp. This is always hairy. They cannulate the aorta to flush the organs with a special solution we use that preserves the cells. I open up the lines to start flushing. The surgeon fills the chest and abdomen with ice. It’s eerie to see the monitor go flatline, even when you know they’re dead.
0430 Liver is packed, paperwork is done. The surgeon is just finishing. I’m sitting on a cooler and nodding off. The OR nurse is STILL TALKING. God in heaven.
0600 I’ve helped the staff do post mortem care, cleaning the body and putting it in the body bag. Tags on. I grab my bags, thank everyone and leave. I stop at Burger King on the way home and have the grossest breakfast.
0700 I pass out. Ahhhh, sweet bed. Why do I do it? Because it feels so good when it’s over.