PixelRN

I've officially moved to my own domain...

www.pixelrn.com 

 I love my new digs... it's like the difference between owning and renting.

I would hope you would all be so kind as to change me on your blogrolls...

A good MICU stretch is receiving a patient on the ventilator in the morning of day 1 and by day 2 the patient gets extubated and downgraded. That almost happened to me the other day...

Day 1: I receive my assignment. Sixty something patient with ARDS. After a lung biopsy, it looks like an interstitial pneumonitis. Not a good prognosis here. She's been on the ventilator for a week now, and we have been unable to wean her. But when I receive her, she is ready to surprise everyone. She survives her spontaneous breathing trial for much longer than we thought possible. The spontaneous breathing trial is the first big step towards extubation...

So she spends the whole day on CPAP mode. What this means is that she is initiating all of her breaths, the vent is just giving her an extra push. Her ABGs are improving, she's looking more comfortable. We let her ride all day long and then at evening switched her back to the previous vent settings, so she could rest.

Day 2: I have the same patient assignment. She looks good. She looks up at me pleasantly. Assessing mental status on a ventilated patient is tricky. You don't know for sure if they are oriented (they can't really answer your questions) so you look at other things. Can she follow simple commands, like squeezing me hand? Yes. She appears calm and comfortable, no anxiety. I get the feeling from her comfort level that she recognizes me from the previous day. She goes back on CPAP mode and continues to do well. I am happy. I'm composing my next blog entry in my head and it's entitled "A MICU Success Story." A couple of hours later she is ready to be extubated. Hooray! Here's one more patient that is going to make it though ARDS! No small feat considering ARDS has a 40% mortality rate.

But will she fly?

So the tube comes out and things start to look kind of iffy. She's tachypneic. Her blood pressure is on the rise. But her 02 sats are holding steady. After 30 minutes I draw an ABG. The results look relatively good. I have been giving her family members time to interact with her and one of them comes to me and says, "I don't think she's really with it."

Crap. This is a bad sign, especially when you consider that poor oxygenation could be the cause. So I go into her room. Now that the tube is out, I can really assess her level of orientation.

"Do you know where you are?" She laughs at me. She thinks this is a silly question. I tell her she's in the hospital. She stares at me in utter disbelief.

"Do you know what year it is?" Again she laughs. Why would I be asking such a silly question? I encourage her to answer the question. "It's um, uh, 19... 19 something."

I ask her to tell me the names of her daughters who are standing around her bed. I point to one. She looks at her with some recognition but can't tell me her name. I point to the other daughter. "Why, that's Mary," she says, without hesitation. I am thinking this is going to cause some serious sibling rivalry after all is said and done.

So now I've established that this woman is experiencing some sort of delirium. What next? I alert the physicians. Everyone automatically thinks of oxygen first, but that doesn't seem to be the answer (her O2 sats and ABGs look good). So as long as she's oxygenating, the physicians are okay with putting this issue on the backburner for the time being.

But I'm a little disturbed. This woman was so cooperative and pleasant when she was intubated. She even greeted me in the morning with a smile, and it's pretty darn hard to do that when you have a breathing tube shoved down your throat. And now she's looking at me like "who the hell are you and what are you doing in my room?" It reached a peak when I went in to give her a heparin shot. "Get your fat face away from me!" she croaked from behind her 02 mask.

I explained the situation to another nurse. Her theory was: "Maybe she thought you had kidnapped her, and felt it was in her best interest to be cooperative with you. When the tube came out and her family was there, she had no more reason to be cooperative to you."

Ha Ha. But I think I know the real reason for this "change." My previous assessment of her mental status was so subjective. She looked up at me sweetly and even kind of smiled with her eyes. I took that to mean she was oriented to the current situation. My instincts were telling me she was oriented, because otherwise she would have been completely agitated.

The moral of the story? Instincts can be useful at times, but you have to remain objective in your assessment. That goes back to Nursing 101.

So what was really causing this delirium? She may have been withdrawing from the narcotics we had been giving her. She had also been spiking fevers.

But here's the worst part of this story. She had been cultured out the wazoo to find the source of these fevers. Nothing had ever grown out. Until now. The resident got the phone call from the lab after we extubated her... The result? She was now growing acinetobacter baumannii in her sputum. So not such a good day after all.

Check out the new Change of Shift, posted at Disappearing John, RN. Great work, John!

The bad news is that I missed the deadline. Again.

The good news is that I moved my computer to a more convenient place in my house AND cancelled my cable TV. What does that mean? Expect more frequent posts, as well as a possible blog re-design a la Kim's "web guy"!

Should nurses cover for the housekeeping and food service staff when they go on strike?

Our hospital is facing a possible strike by the service workers. In the event of a strike, the hospital is requiring the nursing staff to fill in for the services workers. That means that I am required to sign up for extra shifts (12 hours extra per week) in order to cover such duties as answering phones and housekeeping.

I think this is a bad policy for so many reasons.

First of all, it's mandatory overtime.

Second of all, I have worked hard to become a nurse. I consider myself to be a professional. Do other professionals have to cover service workers when they strike? Respiratory therapists? Pharmacists? Physical therapists? Doctors? No, the responsibility falls exclusively on the nursing staff.

Third of all, it implies that I am taking the hospital's side in the case of a strike. I don't even consider myself to be pro-union, but still it seems wrong for me to have break someone else's strike if I do not choose to do so.

Last of all, I do not want to put my health in jeopardy by having to clean hospital rooms for 12 hours. Not to sound like a wimp, but I get lower back pain just from cleaning my own bathroom. Plus there's the minor detail of being 35 years old and 5 months pregnant.

And then there's the question of safety - I haven't been trained on the proper cleaning of a hospital room. This is pretty dangerous when you consider that the majority of our patients are MRSA and VRE positive.

I almost let this matter go. I had been told that the strike is unlikely to happen. But when it came time to put my schedule in, I was required to schedule 12 hours per week of overtime for the entire month of December. I thought this was rather excessive, so I started to do some research. I found the ANA's position statement on mandatory overtime. It defines mandatory overtime as "the hours worked in excess of an agreed upon, predetermined, regularly scheduled full-time or part-time work schedule". Therefore I have declined to schedule myself for the extra shifts, because I believe that would imply that I have agreed to work them. Tomorrow I'll meet with my nurse manager and human resources to discuss the matter further. I'd like to see the official policy in writing, and how it was expressed to me at the time I was hired.

The strange thing is that aside from one or two of my colleagues, the nursing staff seems to be very complacent about this policy. It doesn't seem to bother them in the least.

Of course it would be simple for me to express my dissatisfaction by finding another job. There are plenty of other hospitals in my area. The only problem is that I am halfway through my pregnancy and cannot afford to put any of my benefits in jeopardy.

So what do you all think about this? I would love to hear your feedback.

It seems like every time I take a class (and there are many offered at GHOAT), whatever I have learned about I will soon see in action in the MICU. Last week I took the ACLS certification course. So naturally I came to work the next day fully expecting to either shock someone or perhaps do some chest compressions, or maybe both.

And there she was. She had been in the MICU for a while (never a good thing), and had had a bad night. Every system had gone south. She was in multi-organ failure. Her worsening and hopeless condition had been explained to the family the previous day, but the family still wanted to forge ahead and "do everything." In short, she was an ACLS algorithm waiting to happen.

It's funny, when I first used to come into contact with these situations, I would feel outraged: Here is a woman lying bed, She is oozing serous fluid from every little scratch and old insertion site all over her body. She's unresponsive and all her systems have failed her. She is practically, but not quite dead, and now we have do all this invasive "stuff" to her because we have somehow failed to explain to her family that it's fruitless to continue on with this medical care. It somehow seems amoral. But the situations are never that simple. We have the dreaded "family meeting" (the meeting where the docs tell the family that chances are, their loved one is going to die). It always makes me think of the movie "Dumb and Dumber," where the girl tells Jim Carey that there's only "a one in a million chance that she'd ever go out with him." Jim Carrey is jumping up and down with glee. "Why are you so happy," she says? "Because you said I have a chance!"

But alas, this is not another one of my rants about how everyone in the MICU is dying a horrible death and they should all be showered with palliative care... No, this is a story about ACLS.

So realizing that this is my fate for today, I go on to take care of my practically dead patient. I still talk to her and let her know what I am doing because, after all, who knows? Maybe she's still in there somewhere. She may even be hovering over the bed, just killing some time, waiting to meet her maker. Perhaps she is finding amusement by watching me blunder about in her room. She's been in A-fib all night but now I am watching her heart rate increase even more rapidly. 120s. 130s. 170s. I call the medical team to the room and right away the fellow says, "Time to cardiovert!"

See, I just knew that there was an ACLS algorithm in store for me that day! And it's an algorithm that I am not experienced with - synchronized cardioversion. Of course I aced the asystole and PEA algorithms because that is mostly what we see in the MICU. I'm all about pushing epi, atropine, and bicarb until the cows come home. But anything that involves electricity I am hopelessly inexperienced with. So I put the pads on her. The resident is turning on the AED and a nurse is showing her how to set it up for cardioversion. They set it to 50 joules and SHOCK.

OOPS. They forgot to put it on "synchronize" mode. Now my patient is in V-tach. So now she gets the REAL SHOCK. 200 Joules. And moments later she' s in a normal sinus rhythm. Just. like. that. It's amazing. She's still dying, (and would later die that night, surrounded by her family.) But I watched her heart being manipulated by electricity and it was truly amazing.

The moral of the story is that now I will never allow that mistake to happen to one of my patients. This is a very scary but true thing about nursing. Once you make a mistake (or witness a mistake being made on your patient) you will never allow this mistake to happen again. I will always remember my first cardioversion, and how easily you can send someone into v-tach by neglecting one small step. In fact, there is no such thing as cardioversion in my book. It's called SYNCHRONIZED cardioversion.

***********************************

Faithful readers, (and I wonder how many of you are still there out there since I have been neglecting my blog for my adventures in reproductive endocrinology) you may be wondering how I have managed to start posting again. Ah, the magic of pregnancy. You see, I am now at week sixteen. A few days ago I woke up and decided to clean my entire house. Instead of cleaning maybe a room or two and then pooping out (like I usually do,) I ended up actually cleaning the entire house. I was shocked when I looked back at all the work I had accomplished. The next day I did a twelve hour shift, came home, made dinner, and actually did the dishes. What in the heck is going on? I wondered. Well yesterday I was reading a pregnancy book and it said that week sixteen is when you get all of your energy back. It's like clockwork. And I intend to milk it for all it's worth because who knows when the energy will disappear again? I'm guessing sometime around week 20.

I did not have a good feeling about this patient. She was what was known as a "trainwreck," something wrong with every system. Had an operation, many complications, slow recovery, rehab in a nursing home. When I went in to assess her though, she was not intubated and was able to communicate her needs to me so I figured that she wasn't so bad off after all. But her oxygen saturation kept rising and falling and she was having very frequent PVCs. I started to develop a bad feeling about her.

She was relatively comfortable until about halfway through the morning. Then she started calling for me. I found her short of breath, anxious, and diaphoretic. I asked her if she was in pain, she said no. "I. JUST. CANT. BREATH!!" She managed to say. So I went up on her oxygen more and more, but to no avail. I ran out to get a doctor. "Okay," the resident said, "I'll be right there."

I rushed back to her room. I held her hand and tried to talk her though the anxiety. She looked up at me and said, "I'm going to die, aren't I?"

Oh crap. My more experienced colleagues had warned me about this. When a patient looks up at you and tells you they are going to die, their instincts are usually right on target.

I lied and said, "No. You are not going to die. We are going to get you through this."

"But who are all those people in the white robes?" she said.

Oh double crap. Now she's seeing the angels. I ran out to get the resident. "You really gotta come to room 7. Quickly." As I rushed back to her room I noticed an unusually large number of physicians walking around the MICU that day with long white lab coats on.

I asked her, "Are those the people with the white robes on?" I pointed to a group of doctors.

"No," she said between short breaths. "These people have white hoods on."

Oh triple crap. This is it. Here we go. She's seeing the light. Now I'm the one feeling short of breath. It's only a matter of time now before I am going to have to pull the code bell.

Just then I glanced outside of the room. I noticed a new resident walking by. A new muslim resident. A new muslim resident with a white head covering on. Moments later a pharmacy resident walked by, also a muslim, and also wearing a white coat and a white head covering.

I pointed to them. "Is that who you mean? Are those the people with the white hoods?"

"Yes! What are they doing here? Am I going to die?"

"No. You are not going to die." And that time I was being truthful.

Finally a couple of residents came in to the room. They diagnosed her immediately. Flash pulmonary edema. She missed dialysis while being transferred to GHOAT. Meanwhile we had loaded her up with fluids because she was a GI bleeder. Within minutes she received morphine, a couple of sublingual nitroglycerin tabs, and a huge dose of lasix.

Within minutes she was feeling much better. As a matter of fact, I was too.

The patient was admitted to me from the ER around midnight. I remembered him from a previous MICU stay. He was very sick with a terminal condition and he had not been taking his medications. When he came to me he was wide awake, talking, asking to get out of bed. I felt as if he looked sick but it remained to be seen just how sick he was. We couldn't pick up anything from his pulse ox because of his poor peripheral perfusion. He was tachycardic. He asked me to use the urinal twice but was unable to make any urine. When an ABG was obtained, we were able to see the full story. He had worsening metabolic acidosis. He was breathing very rapidly in order to compensate. The resident came in and attempted to consent him for intubation. The patient refused to answer the question. He kept asking for ice chips and water, which are like the controlled substances of the MICU. The narcotics flows freely but the ice chips and water are carefully guarded, especially for the patient who is on the brink of being intubated.

So back and forth they went. The resident simply could not get a straight answer out of this guy.
"Sir, will you agree to have this breathing tube placed?"
"All's I want is some ice chips!"

And all of a sudden, he stopped talking, his limbs started shaking violently, he looked up at me scared and confused, I grabbed his hand, and then he just went limp. His heart beat stopped, his ceased to breath. In a sense, he died.

But of course being in the MICU, death was not necessarily the end for him. We immediately began resuscitating. The code alarm was pulled and within seconds there was twenty people surrounding my room, eager to participate. This was not my first code but it was certainly the first one that completely took me off guard. I was just telling someone the other day that I had yet to do chest compressions and I felt as though I had better jump in and do it the next time the opportunity presented itself. To me it was the most intimidating part of the code. You need to really have muscle behind it. You pound someone's chest until the ribs crack. I just didn't know if I had it in me. But I was standing there, right at his chest. Another nurse had begun bagging him. So I started pounding away. I don't know how long I managed to do it but I eventually became winded. And the charge nurse (who was one of the few people I had confided in about my early pregnancy) screamed, "Someone take over compressions for her! SHE'S PREGNANT!"

So I guess that was the official announcement to my workplace that I was pregnant.

And I so I started pushing the drugs, which is what you're supposed to do if the coding patient is yours, because it is assumed that you know which lines are available to use.

And then he was alive again. Not alive, alive, mind you. But he had a blood pressure and a heart beat so he wasn't dead. And now he was intubated. Later the resident came up to me and asked, "I did the right thing, right? He wouldn't answer me so I had no choice." And it's true. You must do everything to sustain life unless the patient has told you he wanted otherwise. I completely agreed with his decision.

It was his next decision that I did not agree with. The resident, after consulting with the on-call fellow, decided to put him on high frequency oscillatory ventillation, or HFOV. In other words, we were going to switch him from the regular ventillator to the oscillator. I didn't understand why. I mean, I understood the obvious answer, which is that he wanted to correct his acidosis and he didn't think the ventilator was going to cut it. I do understand that logic. But by that time his pH was 6.73. and his CO2 was in the 90's. What I wondered was how was he going to FIX the acidosis. Sure you can temporarily CORRECT it, or at least get it up to maybe 7.15 (which still really sucks).

But at that point you are simply chasing your tail. Antibiotics do not work fast enough. I am finally starting to learn these things from my own direct observations. When the pH goes that low, the blood sugar will also start to drop, precipitously. So it seems like all you are doing is pushing Dextrose-50 and Sodium bicarbonate, and waiting for the patient to die. So far I have not seen anyone bounce back from that scenario. If and when I do, it will make a believer out of me. Heck, if anyone out there has a story about someone bouncing back, please share it with me, it also may make a believer out of me.

But the oscillator? I really got this sense that they were just "playing around", that it was more for research and experimentation than for actually curing the patient. Did I mention that his 'terminal condition' was end stage AIDS?

He coded once more during my shift and again we brought him back to life. At 7 AM I gave report to the day nurse. I left thinking that when I returned that night there would be a 50/50 chance my patient would still be alive. I would not be surprised by either outcome.

As it turns out, he didn't even make it until noon.
I asked the charge nurse how it all ended.

"Well, he coded three more times before 11 AM. The third time I went in and said, 'Does anyone have a problem if we call this?' " The fellow (who had OK'd the use of the oscillator) agreed that it was time to call the code.

I am finding that the more experience I get, the less things surprise me. But this one really left me astounded. Did the physicians really think they were going to turn things around for this guy? How many times can you code a person and still have a chance for a successful outcome? And as far as the oscillator is concerned, has anyone else out there seen it used to reverse severe septic shock? (And I mean for an adult patient, not a nenate or a peds patient, when I know it used more frequently). I would really like to have a physician's perspective. What goes through your mind? Do you simply have this singular vision of saving the patient's life at any price, and with any tool at your disposal? Does it sometimes take an outsider to step in and give you a different perspective?

To be fair, this did take place on the weekend, and the MD team that was taking care of that patient did not have the benefit of having an attending to advise them. Most of our attendings are quite good at taking control of the situation and deciding when 'enough is enough'.

But I work at a teaching hospital, where our three-fold mission is "patient care, teaching, and research." Sometimes it doesn't seem to fall in that order. As it turned out, the fellow who approved the use of the oscillator had actually been focusing his research on HFOV. It makes you wonder. What if he had been focusing his research on Xigress? Would there have been a different outcome? I guess the other side of it is that this teaching must take place in order to produce competent practitioners. Our wonderful attendings, they aren't born that way. They also had to go through the process of trial and error, and learning by observation.

It's been awhile, I know. Let me fill you in. As some of you may know from reading an earlier post, I was beginning a round of IVF. Well, it worked! I am currently 11 weeks pregnant. Despite the frustration in the beginning, when it actually came time to do the egg retrieval and the transfer, everything went surprisingly smooth. It was actually kind of interesting and yes, fun. It's ended up being a great experience. The most difficult part was waiting the two weeks in between to take the pregnancy test. I suppose the last 10 weeks have been difficult in that all I could think about was getting over that 12 week hump and thus significantly decreasing the risk of miscarriage. I'm quite sure every woman goes through that when she conceives but I think it may have been slightly more difficult for myself. You see, we have been trying for over two years so when the postive test came back I just didn't quite believe it. And because they never really diagnosed our infertility, I kept thinking, this it, I 'm probably going to miscarry. But the little one is still here with me. I know because I heard the heartbeat this morning. So even though I am 5 days away from the magic 12 week number, I'm starting to feel much more secure about the whole thing.

I'm sure everyone's heard about the fatigue associated with early pregnancy. I'm feeling it but it's not what I thought it would be. When I go to work I feel great. I have energy and motivation. I'm not thinking about being pregnant. I go about my job with a sense of purpose. It's only when I have a day off that I can't get out of bed and I feel this strange but wonderful lack of motivation. It's as if all my energies need to be focused on maintaining the pregnancy so I just lie there on the couch, watching TV, reading, and eating. It's heavenly laziness and I deserve it. Of course, I'm also walking a lot because I obviously need exercise and so does my dog.

Hence, the lack of blogging. Blogging is not needed to maintain the pregnancy, therefore it falls by the wayside. But like I said, I continue to work, and the MICU is never a dull place. Blogworthy things continue to happen and I will be recording them in the very near future.

Okay, I'm a a little late in the game (these 12 hour shifts are killing me) but here it is...

Change of Shift is the new nursing blog carnival started by Kim over at Emergiblog.

Kim is one of the God-mommas of nursing bloggery and she has done an excellent job of putting all of this together. Thanks Kim!!! I hope everyone out there will continue to read and contribute to this new blog carnival. I know I will.

About a month ago I was ready to quit the MICU. Instead I decided to stay and "fight the good fight."

So here's round one:

On Monday I assume care of a patient who's going on day 90 in the MICU.

I know her story well; I've take care of her at day 18, day 45, and day 67.

She's young. Multiple MICU stays after complications from a transplant, but she is a fighter. Last time she was here for 9 months and no one thought she would pull through but she did.

So we forge on even though her case is looking more and more hopeless. She is the picture of agony. On her face is grief, pain, fatigue. The medical team has expressed that they are extremely doubtful that they will be able to get her out of the MICU.

When I take her pillow away from her head to readjust it, her head stays elevated, rigid. I take a pillow out from her legs and her knees remain bent, suspended. She is extremely cachectic. When she is awake, she cries. The family thinks that she is this way because the nurses are "sedating her too much."

During my spiel at AM rounds I suggested a palliative care consult to the physicians. I am not told yes or no, I am simply ignored. I ask them for a response. "Yay or nay on the palliative care consult?"

From the attending:
"Well, we don't want to call in palliative care, because we are afraid of making the family mad. Also, we have to defer to Dr. Magicalmiracle, the surgeon who performed her transplant. "

Later, one of the transplant attendings came around. I followed him and waited to get his attention. I asked him about his thoughts on this patient's recovery. Does he think she has a chance? He replies that she was this bad last time around and she made it through. I asked if she was this cachectic. He says he's not sure. He also reminds me that Dr. Magicalmiracle, who performed the transplant, is the only person who has any say in what direction we are taking this patient. I tell him that the patient really appears to be suffering and was wondering if he would consider palliative care.

He replied that he would pass that info along to Dr. Magicalmiracle.

Boy was I ever naive.

I wish that someone had told me that YOU DO NOT MENTION PALLIATIVE CARE TO A SURGEON, ESPECIALLY A SURGEON WHO PERFORMS MAGICAL MIRACLES.

Later on the patient's mother was in to visit.

We talked about her daughter's life. We shared stories about her. I asked her if she thought she would make it through this stay. She told me no. She had said to her daughter recently, "B, we just need to get you out of this hospital and home to us." B looked up at her mom and mouthed the words, "No, it's not going to happen." In light of this I asked her mom if she had ever considered palliative care. She said what's that? I explained to her that it would mean changing the focus from getting B back to her original state of health to providing her with as much comfort as possible, taking away some of the more invasive treatments, letting her rest, getting her to a more peaceful room. The mom took all of this in and thought about it.

I left work that night feeling conflicted. I felt as though I did the right thing. My instincts were telling me that this patient was hanging on for the sake of everyone but herself. I was worried that no one would follow up on this. I emailed one of my resource nurses and told her about my frustration. She said she would follow up on it.

The next day she said that she had set up a meeting between our nurses and Dr. Magicalmiracle. Would I mind being the primary speaker since I was the one who set this in motion?

So now the game is on. I called the palliative care nurse for advice. "What the heck do I do? What do I say"

We talked about some strategies. Don't pick a fight. Stay away from any emotional aspects of it. You are just setting a precedent for further communication between the surgeon (who was calling all the shots) and the nursing staff.

In the end I decided that all I really wanted to convey to this doctor was that we needed to hear from him what his goals of care were for her, what her chances of recovery were, if he thinks she can get out of this nutritional deficit. I wanted to tell him that the nursing staff was really becoming discouraged and so if he is still hopeful, then we need to hear it from him. We need to here his battle-cry.

Did you ever have a meeting with someone that was entirely civil, cordial almost; conflicts and grievances were aired out, you come to some resolutions... but then you walk away with this feeling that you just got screwed, hard.

He had the same wry smile on his face the entire time.

He started out by saying "Any first year medical student could tell that this woman has a very slim chance of making it out of here. But we discussed this ahead of time and she made it clear that she wants everything done, to not give up until the end."

Then he said that it was brought to his attention that our nursing staff had been mentioning palliative care to the family, and letting them know that she was suffering. He said this was unprofessional and highly inappropriate. he said if we express to the family that she is suffering, we are responsible for making the family suffer many years down the line, wondering if they had done the right thing.

But, I said, nursing is with her 24/7 and she is indeed suffering. It's hard not to let the family know this. I'm not sure how the family can look at her and not know that she's suffering.

Well, it's a tough business, he said, with that same wry smile.

Also, I reminded him that our attending had met with the family last week and conveyed to them that he had very little doubts that she would be able to make it out of the MICU.

He said, "That is a conversation that should only take place between an attending and the family or the patient. For anyone else to do so is highly inappropriate."

I wasn't sure how to take this. As usual, I deferred to my lack of experience. I felt bad for acting "unprofessional and inappropriate." I guessed that somehow I had crossed a line that I wasn't even aware of in the first place.

But I also felt outraged that this surgeon refuses to go into the room and do a physical examination of her. All he does is walk by her room, glance at her chart, and give her the thumbs up. I would hardly consider that "doing everything." And what about when our team dropped the ball on her nutritional status. He says he is doing everything, but did he step in and demand his patient receive TPN? No.

I also felt like a pawn. If the doctors believe that no one should mention palliative care except for the doctors, and palliative care nurses believe that the nurse should be introducing the concept of palliative care into the picture... then I am stuck in the middle. I am being taught to advance the palliative care nurse's agenda which is in opposition to the physician's agenda.

That somehow doesn't feel right.

I guess you could say that I have lost round one of "fighting the good fight."

It's scary being a transplant patient in the MICU. You are crammed into a room with various multi-drug resistant bacteria and fungi running rampant (and possibly even lice.) You wake up for one brief moment of terror, only to have the nurse press a few buttons on their IV pump and put you back to sleep. Eventually you manage to stay awake long enough to ask if you can die, and you are told no. You are not allowed to change your mind. You have a paper and pen in front of you that you manage to write "DNR!" on but that only means they need a second opinion to assess your competence. Then a fleet of first year psychiatry residents are unleashed into your room to determine what kind of drug therapy can make you not want to die. You don't think they've invented the drug that takes away the depression of dying in an ICU, but you never know. Maybe cocaine would work. You hear bits of conversations of nurses talking about what the had for dinner or what their plans are for this weekend and you are drenched in your own stool but have no way of conveying this to anyone, except perhaps by the smell.

A tough business indeed.