Monday, August 07, 2006

All riled up

I don't even know if I spelled "riled" correctly and now I'm under pressure to be grammatically correct, after the last post. I was really mad last week. I'm better now, but still feel the need to SHARE MY WRATH with the blogging world. And I'd better type fast, cause the Little Einstein videos only last 30 minutes, and I've already spent 10 minutes yapping on the phone. BTW, I think biscotti from the local coffee joint are totally acceptable teething biscuits, albeit expensive ones.

Anyhoo. Last week I got called out for an organ donor referral to a teeny tiny little community hospital with a not-so-great reputation. Although, in all fairness, once when I was younger I smashed my finger at work and they did a top notch job of taking my finger nail off and stitching a little laceration I had. The finger nail never grew back in the right way, but I guess that's not their fault. Anything larger than fingers, though, I'd be afraid. That's all I'm saying.

The patient was a middle aged man who had minor surgery the day previous, went home with a headache and had an enormous bleed. He came in after midnight. It's now the following afternoon. His blood pressure has been 60/30 for 10 hours. He's not on any meds to keep his pressure up, just IV fluids. He also has a lot of medical problems, but his liver numbers are good, so we proceed. The hospital called 45 minutes the first clinical was done. He's not going to make it long with his blood pressure in the toilet, so I will have to ask the family pretty quick.

I get there and the patient is in nuclear, getting a cerebral blood flow (with a pressure of 60, you're taking him off the floor? Nothing like a code in radiology, I always say). I have already introduced myself to the family practice resident who's handling the ICU. There are no intensivists, no hospitalists. Any orders needed, the attending(s) have to be called. Another WTF, as Kim would say, but whatever. When the patient returns, she says she's going to speak with the radiologist and talk with the family. I ask her if I can be present. She says no, it's a conflict of interest. I ask her if, after she's done talking with the family, could she introduce me. No, that's also a conflict of interest. Really, cause at the other hospitals I go to it's called a "collaborative approach". Apparently she can't even be SEEN in the same room with me or it may imply that "I only want his organs" to the family.

All right, let's review:

  1. They do nothing for the patient for 10 hours except scan his brain and give him IVF's.
  2. They call us late. We should get the referral when the patient has a Glasgow Coma Scale score of 5 or less, not 45 minutes after the first doc says he brain dead.
  3. Working together to ask a family to consent for donation is not unethical. Being pro-donation is not unethical. Possibly being a medical person and hindering the donation process may be unethical, but more on that later.

Finally, I ask the nurse to introduce us and to come in with me when I speak with the family, since she's been working with this patient all day and knows the family as well as anyone. I bring them into a conference room. There's the wife and two daughters. First, I assess their understanding of brain death and they get it. They know he's gone, they just don't want him to suffer. Understandable. Then I say to them, "Because of the way he died, (the patient) has an opportunity to save someone else's life through organ donation." The first daughter immediately says yes. Mom is unsure, but she defers to the daughter. The first daughter and the nurse both say how it would be a great thing for him to save another life and then the daughter says that he won't need his organs in heaven. The second daughter is distraught. We comfort her as best we can and she says it's okay with her. They all want to go back to the bedside and I tell them that in a little bit I'll have paperwork to go over with them, when they're ready. I give them an idea of the timeline and assure them that he will be able to have an open casket.

I go back to the nurse's station and start making phone calls. By now, a colleague of mine has arrived to help me out. We both note that the first clinical is not completed correctly. It has no time on it and it doesn't note if the patient is spontaneously breathing or not. She calls the neurologist back to see if he'll come and correct it or if we can fax it to him. I should note that the hospital system that this hospital belongs to uses a check list for brain death, for comformity and clarity, since many docs don't do this often and aren't familiar with the process. This one hospital doesn't use it, they have kept their own brain death policy. So it's just written in the progress notes. She gets a hold of him and he refuses to come back or have it faxed to him. He'll be in the next day, he says. She tells him the organs won' t be viable by then. He says that's not his problem.

The next thing I know, Dr. It's-not-ethical comes out of the patient's room and says, "They changed their mind." I'm suspicious. I go over to the daughter. She says that she wants to, but the rest of the family, the extended family who are now filling the room, don't want to. "And I can't go against the whole family." I talk to her for a bit, without being obnoxious about it, to see if there's anything I can do to change her mind. She's says she'll call if anything changes, but with a systolic blood pressure of 50 he won't last much longer. My colleague and I start packing up. I hear the resident and her attending going over the brain death policy. I offer to clear up anything for them. They just look at me. Then I mention that if this had stayed a consented case, we really would have needed a time on that first clinical for it to be accepted by the transplant surgeons. For it to be LEGAL. They go back to talking and ignore me. We leave.

Several days later my colleague gets an email from the nurse manager of the unit. I'm too flabbergasted to editorialize, so I'll just post it in full.

I also need to let you know that there were multiple complaints about the last referral in ICU by both the resident and the primary nurse with regards to the person who approached the family. They felt that she was placing the burden of approaching the family on them because she was not comfortable doing so. The resident tells me that she was placed in an uncomfortable position by your rep. In addition, when she finally did approach the family - the both stated that she was not assertive and they were not at alll surprised that the family refused. This is feedback that I am getting from my staff and physicians that I thought you should know (signed, the nurse manager)

Do I even need to say that this is complete bullshit? And hello-I did get consent. And then got it rescinded due to extended family pressure. Listen, it's hard enough to get a transplant. Why make it harder? And for the resident who's so concerned about ethics, think about this: you took an oath to preserve life. When your patient has an unsurvivable injury and you have stopped treating them in any meaningful way, the onus is now to preserve the lives of the prospective recipients. You are no longer saving one life, you're saving up to 8 lives and if you fuck it up you're potentially harming 8 lives. So put that in your Hippocratic Oath and smoke it.


PJ Geraghty said...

This is an after-action review waiting to happen. Especially if you have a medical director who is not a transplanter, perhaps he/she can be influential. Some discussion of catastrophic brain injury guidelines might be useful as well, since all of this was complicated by the "rush factor" of a pressure of 60 systolic.

Good luck. Hope you can turn this hospital around.

Anonymous said...

"...teeny tiny little community hospital with a not-so-great reputation."

I'm thinking, if it's a small place as you described, there may be educational issues here surrounding roles and requirements of organ procurement. Perhaps a conversation between the DON at the facility and someone from yours may be in order to clear things up...just a thought.

Do you find this to be commonplace at smaller facilities?

Anonymous said...

as a mom of two liver recipients I am flabbergasted that any hospital, small or not, still has doctors and other staff who are that heartless and uneducated. The doc who would not come in or even receive a fax needs to retire since he has obviously lost any sense of compassion.

mother jones said...

It's sad to hear about about these things. I think education is an important key in procuring organs for transplant. Our state transplant team came to our hospital a few years ago and talk to the nursing staff. I learned a lot.

Your writing shows that you are a passionately dedicated health care professional. Thank you for all your hard work.

TC said...

Actually, the hospital services manager is going back there for an after action review. We do education there a few times a year, as we do all hospitals, as well as quarterly chart reviews. They have been resistant to even receiving criticism, let alone make changes. I let you know how it goes.

We have had success with our medical director, a doctor, talk directly to the doctors we have problems with. That puts me off a little, like why can't they just here it from us? I know what I'm talking about even though I'm not a doctor, but if it works, it works.

Sid Schwab said...

Wow! Sometimes my fellow physicians can be incomprehensible idiots. Thanks to you for being willing to be on the firing line of a very difficult situation, and for writing so well about it.

livermom said...

Sorry to hear about your day. What a disappointment that within the medical field, there are professionals that don't seem to grasp the importance of donation. Thank you for all you do. Many appreciate you on a daily basis! Hope they pull their heads out of their...

Amanda M said...

Just really darn glad that people like you are out there getting what has to be a super hard job done.

The thing with organ donation - you just never know when someone you desperately love might need one. I sure as heck didn't. So it's in all of our self-interests to have a system that works and if the staff at that teeny-tiny hospital aren't so interested in helping, I might just have to send Katie to have a small chat with them. Kidding, really hope the after-action review helps. Lots.

- Amanda, aunt to Katie, age 8, biliary atresia (docs tell us that someday, hopefully not soon, she will need a liver tx)

angie said...

Thanks to people like you organ donation is on the rise. We are so thankful!! Our daughter received a liver tx at 7 mths. old. She is now 3 and so full of life!! I think it would be a very difficult decision to have to make if I were on the donor side, but if I knew it would help someone else it would ease the pain. Thanks for helping people to understand the value of organ donation.

Anonymous said...

Sounds like home. :)

Kath said...

First time reading your blog.

My heart goes out to you for your efforts. Please try not to let situations like this get you down even tho I know they do.

You are an angel on earth and I applaud your passion and your efforts.

Bless you.

Anonymous said...

A co-worker of mine who is also a clinical coordinator (donor care manager)& I were discussing this very issue yesterday. Since CMS & JACHO require hospitals to participate in the organ donation process or loose funding,& it is a very specialized area of practice as well as time-consuming, you would think hospitals would be grateful to have professional people come in & perform this service for them. Instead, as a staff, we are reminded by our manager that we are a GUEST in our state's hospitals & we must always be polite, deferential, stay out of the way, & not rock the boat in any way. I am fed up with the attitude that our OPO needs the hospitals; THEY need us! I often have a hard time observing the care I see given to the donor patient. It's like "they're dead; how much care do they need?" I know it is imperative that the donor patient be given the best of care so those precious organs they and their family are offering are in the best possible shape for the recipient(s) to have the best chance for a successful transplant. I use the above as part of a little spiel I give the nurses caring for the donor patient to help them understand the importance of those (not-so) mundane interventions such as positioning with the head @ >30 degrees, q2h mouth care & reposi- tioning (to prevent a ventilator- associated pneumonia), and giving medications & drawing labs on time. The other persuasive argument I use is 'if your loved one were waiting for an organ donation, wouldn't you want the donor to be given the very best possible care?' I know nurses and doctors are human too, but I can't begin to figure out why they work against us instead of with us. They, or someone they love, could easily be in need of an organ donation some day. Or someone they love may have a TBI and the only solace they may receive is through organ donation. I hope Karma will be gracious to them & not use that time to make itself known.
I love what I do because the good far outweighs the bad, but some days I really just want to scream.

Anonymous said... a fellow Organ Coordinator, this scenerio is all too familiar. After actions are only good if there is follow up with the physicians (because they sure won't be presesnt!). HD needs to do some education for sure. It is a shame the opportunity was essentially taken away from this family. Best of Luck