PixelRN

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.

Florence Nightingale created the nursing profession based on her belief that dirt was at the root of all all sickness, and cleanliness=good health. Interestingly enough though, she rejected the germ theory of disease. Perhaps she would have liked this story:

------------------------------------

My patient had a bug in her urine.

Escherichia coli? Proteus mirabilis?

Try Pediculus humanus, more commonly known as "lice."

Lice?

Yes, lice. At least that's what the night nurse told me. I had collected a urine sample from my patient before the end of my shift. The patient had been presumed anuric (unable to make urine) but when I found evidence to suggest otherwise, we placed a foley in her and naturally sent some urine off for cultures and analysis.

The microbiology lab had called during the night to say that there was "lice in her urine."

"What?" I said to the night nurse.

"Lice in her urine," He said.

"Come on."

"That's what they said."

I went to the resident. "So what do you think about this supposed lice in the urine? Are we doing anything about it?"

She started laughing. "I don't think it's real. I've examined her and I've found nothing to suggest lice."

I went in to do my assessment. I didn't find anything either. I also didn't find any documentation from microbiology about the lice. But I still had the willies.

During AM rounds it was discussed and the medical team had decided that it was a fluke. Okay, I could get on board with that. I quickly forgot about the whole incident.

Until later that day...

When microbiology results are available they pop up in our computerized chart.

Here's what it said:

"Urine specimen:
A small bug jumped out of the specimen cup.
Recommend lice check."

At this point I was on the verge of freaking out. I went to the fellow. She too was laughing. "It can't be real," she said.

I thought about it. I'm the one who collected the sample. I certainly didn't see any kind of a bug but MAYBE it could have jumped in during the short moment before I twisted the lid on. Or MAYBE the microbiology lab technicians could have been taking acid. I just don't know.

I continued on with my business but the hair on the back of my neck was standing up. I really started thinking. I did notice that the patient's son had dreadlocks. Hmmm. Also, this patient had been in the MICU for 90 days. We have cleaning people who go in and clean the rooms twice a day, but how thorough is this cleaning? Not very. They collect trash bags, wipe down a few surfaces, mop the floor. I've mentioned before how small the rooms are. If there is a continuous dialysis machine in the way of the sink, is the cleaner going to jump over it to clean the sink? Probably not.

It's kind of like this: You know how if you have an old, shabby house you can clean and clean and clean but it somehow never really looks clean? Our unit is an old shabby unit. I started to take a good look around. There are so many nooks and crannies that never got cleaned. I looked at the ventilator arm in my patient's room. It had a blackish green substance growing on it. Yuck. Probably mold.

So it got me thinking. What if a patient who's length of stay exceeded 30 days was transfered to another room just so they could give the old room a good, thorough cleaning? Wouldn't it be interesting if the patient actually improved after this thorough cleaning?

This is probably just wishful thinking on my part. Currently the MICU has far too many patients who have been there for greater than 30 days, and it doesn't look like any of them are getting any better.

So the end of life saga continues. I guess in the MICU "end of life" is just our way of life.

Two more "firsts" for me as a nurse - my first Family Meeting and my first unplanned decannulation (Mom- this means that my patient ripped his trach tube out and subsequently could not breath).

I capitalize "Family Meeting" because there are two types:

family meeting = the docs update the family and discuss ongong issues related to treatment.

Family Meeting = when all of the patient's organs are failing, the patient is zoinked out on the ventilator, and there is little chance for recovery. The Family Meeting's purpose is really just to say "Look, your family member is dying and on life support. So you want us to pull the plug, or what?" (But of course not in those words, and certainly not in that tone.) This Family Meeting was slightly unconventional in that it was held at the patient's bedside, and the patient was able to participate.

So this patient, I'll call him Fred. Fred's reputation preceded him. I had been peripherally hearing for weeks that Fred has "had enough and he wants to die." I did not know why his wish was not granted. He was dependent on the ventilator but was very much awake and cognitive, and could communicate with hand signals, writing and mouthing words. He was in his eighties and had numerous comorbidities. On this day Fred was to be my patient, and there was a family meeting scheduled.

It was a trying assignment. My other patient had a "difficult family" that kept summoning me to her room. Fred was continuously calling me into his room asking me to reposition him. I felt as though no matter what I did, I could not make him comfortable. He wanted a pillow under his feet. He wanted the pillow removed. He wanted the pillow back again. And he also also kept pointing to his trach area asking me to do something to it. I could not figure out what this something was.

So onto the family meeting, at the patient's bedside. Let me paint you a picture. The rooms of the Medical Intensive Care Unit at the Greatest Hospital Of All Time are roughly the size of a walk-in closet. Picture a turquiose painted walk-in closet containing a patient on a bed, an IV pole, a ventilator, a continuous dialysis machine, a sink, wall suction, a supply cabinet. Now place an entire family inside the room. Add a social worker, two doctors, and myself. Kind of like stuffing clowns in a volkswagon.

One thing they like to tell you at these palliative care workshops is that you need to be present at these Family Meetings, so you can advocate for your patient. The docs will want to do everything, the family is too distraught to know what to do. You, the mercy-killing, Kevorkian loving, morphine pushing nurse, has got to be there to say, "Come on people! What are we doing to this poor patient anyway? Let's all come to our senses!"

So here I was in my first family meeting, ready to step up and advocate for my poor dying patient, and all I could get was a back row seat.

Meanwhile his vent kept alarming so add a respiratory therapist to the mix. I could barely hear a thing.

What I managed to eak out from the back row was this: The attending explained to the family that there was very little hope of getting their father off the ventilator. The family said they agreed, they had discussed this with him, they know he wants to die. So they will withdraw care. On Friday (this was a Monday).

So is that what the patient really wanted? As the attending and the family were discussing things, the patient just kept zoning out. As much as he had the ability to understand what was going on, it was unclear if he actually did. It didn't help that his vent kept alarming.

So after everyone left, my patient suddenly "woke up." He kept motioning at his trach again. I couldn't figure out what he wanted me to do. Finally one of my colleagues said, "He wants you to pull his trach out."

"Really?" I asked him. "Is that what you me to do? Pull out your trach?"
He nodded vigourously.

"Well I simply can't do that." This exchange was repeated over and over again.

I was going to go to the docs to let them know of his wishes, but then I wondered, does he know what it means if his trach is removed?

I told him that removing the trach would mean he would most certainly die.

"Is that what you want?"

His eyes glanced off in the distance.

"It's important that you realize that. Do you understand what I'm saying?"

Again he looked away and refused to answer me.

Later he was trying to tell me something else. I couldn't understand it so I handed him the tablet.

"Get me a nurse, " he wrote.

What the hell. By that point I was ready to withdraw on his ass. Instead, I left his room. All of his basic needs were met, I had just repositioned him, I swabbed out his mouth, there was really nothing more I could do except sit there and argue with him. I had tried to therepeuticly communicate with him, but he kept waving his hand in my face. And besides that, my other patient was calling me.

Finally, I got my other patient settled. It was now 15 minutes before shift change and I was free to sit down and do a day's worth of documenting.

Then I heard the alarm. The vent alarm that is. I just knew it was Fred.

(I will tell you that there are about 100 different alarm sounds in the MICU. When I was a student the biggest challenge was in knowing which alarm to respond to. If you responded to every single alarm you would be running around like a headless chicken. You learn pretty quickly that the vent alarm is the one to respond to EVERY TIME. Protect the airway and all that...)

So I ran down to Fred's room. Sure enough he had pulled out his trach. I absorbed that initial moment of shock and panic for exactly two seconds then sprung into action. Thankfully a fellow RN was in the room with me so together we intervened. I paged the respiratory therapist and got my ambu-bag. A resident came in. "Page ENT!" I said.

Before I started to bag I had a moment of confusion. He pulled his trach out. He wants it out. He's been saying for weeks he wants to die. What the hell are we doing here? And besides all that, what orifice am I bagging? I recalled a story from last week when a patient decannulated and the RN started bagging the trach stoma! Was this story relayed to me because it was correct or incorrect? Bag the stoma? bag the mouth? AHHH! I looked down at the stoma, it didn't look like something I could bag so I bagged his mouth. Within moments there were doctors and nurses in the room, as well as the ENT doctor and and the anesthesiologist. I was bagging his mouth and someone had put an occlusive dressing over his trach stoma. His sats (which were in the 40's) came up to the 80's. I asked the resident, "So what are we going to do here?"
He said, "What do you mean what are we going to do? There was a family meeting. We have to put in a new trach."
"He pulled it out."
"Are you sure?"
"He's been begging me all afternoon to pull it out." Either he pulled it out or an evil MICU elf jumped up on chest and pulled it out.
Meanwhile the ENT doc put in a new trach, within seconds. When it's an airway you're talking about, there's not exactly time to debate ethics.

The resident asked Fred, "Sir, did you mean to pull out your trach?"
Fred refused to answer.
"Was it a mistake, Fred?"
Fred looked up and nodded weakly.

The resident said that there was nothing we can do.
"Well you have to do something."
"I'm not withdrawing care on him."
"I'm not saying you should, but unless you either order mechanical restraints, chemical restraints, or a 24 hour sitter, we will be reliving this drama on a daily basis until Friday."

"I don't want to restrain him."
"I don't want to restrain him either. Order a sitter. Get him sedated."
A sitter was ordered and some midazolam was added to his regimen.

All the nurses who knew Fred were pretty pissed off. "That man has been begging to die for weeks. What the hell are we doing?"
Someone suggested I call an ethics consult.

I had considered it. But despite his kamikaze reputation, I found him to be ambiguous. He would not convey to me that he actually wanted to die, just that he wanted the trach out. And he denied that he meant to rip it out himself. Not that I'm blaming the man for being ambiguous. I mean, it's death we're talking about here. No small decision.

I gave report to the night nurse. I told her that I kind of panicked when he decannulated, and was confused because someone had just told me about the nurse who had bagged the stoma instead of the mouth.

The "nurse who bagged the stoma" just happened to be in the room. "Oh that was me. The reason I bagged the stoma was that it was so huge. It was bigger than her mouth. I guess I was just following my instincts."

At any rate, next time I will know exactly what to do.

Cover up the stoma and begin bagging with the mask. It bears repeating: Cover up the stoma, bag with the mask. Cover up stoma, bag with mask. And page ENT. And call for help.

The night nurse said, "Oh that's such a great learning experience. I'll bet there's lots of new nurses that need to be reminded of what to do. You should write a piece for the MICU Fly By." (the MICU Fly By = our incredibly archaic xeroxed quarterly newsletter.)

MICU Fly By my ass, I thought to myself. This one's for my blog.

Here is an update:
My patient that I was so convinced could be extubated?

Extubated the next day.
Developed airway edema.
Had to be reintubated.

I found this all out when I came to work two days later. So I was wrong. She didn't fly.
You see? I still have so much to learn.

And learn I shall. After the interview for the psych nursing job, I have come away with a new perspective. I was told that there are two RNs per unit in the psychiatric facility. One RN hands out meds to everyone and one is in charge of the unit. Neither of these roles/tasks have any interest to me so I declined the job.

The hospice nursing interview hasn't materialized yet.

So I came home and wallowed in depression for about an hour. My husband helped me by rattling off every other conceivable type of nursing that I could try:

Radiology? Too boring.
IV therapy? I suck at phlebotomy.
rehab? Not much demand for nurses there.
oncology? Probably the worst things I hate about the MICU, only magnified.

My husband gave up and I finally went off and sulked by myself. And then I really started to do some serious thinking. What do I really want to do? Two personal idols of mine came to mind: Martha Stewart and Andy Warhol. (Neither have anything to do with nursing, but bear with me). Okay, so in my wildest dreams I would really like to be a wildly successful creative marketing genius nurse. Should I get my MBA? No, another degree would be crazy at this point. So what do I need to do? What would Martha or Andy do? What would Florence do?

And then it hit me. It's not the job. It's not the unit. It's not nursing. It's me.
I need to learn how to kick ass.
As a nurse.
As a MICU nurse.

I thought about my last post. I really am chicken-shit when it comes to talking to the doctors. Why should I be? They need my perspective. I am at the bedside constantly. I have the information that they need to make their clinical decisions. So what if I every conversation is an interruption? And they interrupt me constantly. The MICU is really just one interuption after another. That's just the way it is. I need to get over this. Also, I should talk to our attendings more and learn not to be intimidated. They are a wealth of information and they LOVE TO TEACH. I should be taking advantage of this!

Also, I hate asking people for help. For god sake's, I tried to place a foley catheter in an obese woman BY MYSELF. What was I thinking? I need to get over this. When I need help I will ask the first person I see and I will not hesitate. They can always say no.

And as for feeling disgruntled with my role of "gatekeeper and dictator of information" and as "one who carries out orders?" That is my role for right now. I managed to actually enjoy 10 years of waiting tables. I loved it. I loved the pace, the atmosphere, making things happen under stressful conditions. And yet it never bothered me that I didn't have any input over what gets placed on the menu. The chef was the decision maker. (Once, very briefly, I entertained the idea of going to chef school until I realized that they work longer hours and get less money for it. )

So I resolved to remember what I love about nursing (the pace, the atmosphere, making things happen under stressful conditions). I went to work the next day with my new attitude. It helps that I now have an iPod nano and so during my 10 minute walk from the parking lot to the MICU I can listen to psyche me up songs from the 90's like Liz Phair's "6'2", the Foo Fighters' "Monkey Wrench". And "Waitress in the Sky" by the Replacements.

When I got to the unit and was handed my assignment, I realized that the forces of the universe were somehow aligning as if to confirm my decision. At the risk of sounding like "Agnes of God", it was almost as if my assignment was handed straight down from God, Himself.

The thing He handed to me was an end stage liver patient. He was denied a transplant because of a cancer history. And he was not in liverland. He was alert and oriented. He had a bad pneumonia and was requiring 100% 02 by non-rebreather mask. The question was whether he wanted to change his status to DNR/DNI. DNR/DNI = legal status of do no rescucitate (using CPR), and do not intubate.

This is the situation that I hear about at every palliative care workshop I have ever attended. This is what they prepare you for. And yet, after almost two years here I have never been faced with this situation.

The patient was faced with imminent death. If he wasn't intubated it was likely that he would die. If he was intubated it was very possible that he would develop more complications and die on the ventilator. But instead of the family or the physicians calling the shots, this patient was still in a position to make his own decisions. As his oxygen saturation dropped to the low 80's, I notified the resident. It was time to take the next step. The resident went into the room to have The Conversation.

The patient was still unsure. He had just begun to make peace with the fact that he was dying. But faced with air hunger, pain, and anxiety, and with his family all around him crying, the poor man looked up and said "I don't know! I just don't know!"

The physician said, "Then when the time comes, we will intubate you because that is the default. Do you know what default means?" The patient was confused.

(As the physician tried to explain what the word "default" meant to this dying, anxious patient I wondered why physicians have so much trouble explaining things to patients in a language that they can understand. Who wants to learn new vocabulary words on their deathbed?)

The physician left. The family went to the waiting room so the patient could rest some. I realized that it was just me and my dying patient. At every palliative care workshop I have attended, they always make it sound so easy, like DNR/DNI is the obvious choice. Let me tell you, it's far from easy.

How easy do you think it is when you know you could die in the next hour? Sure, you know you've been dying of liver failure for the past five years. It's a terminal disease. But if intubation could buy you just a little more time would you do it?

I forgot about all my little MICU tasks, (and my other patient who was stable and snowed on the ventilator.) I spent the rest of the afternoon trying to helping this patient, and to make sure that he wasn't alone. By now his pain was increasing. He had a Fentanyl patch and PRN morphine but it wasn't cutting it. He was torn between knowing that he wanted to say goodbye to the rest of his family who were on their way from out of state, and knowing that he just wanted enough Morphine to knock him out. I asked the physician to up the dose several times. It still wasn't working. And as his pain worsened, so did his his oxygen saturation. Finally I told him that I could get him more pain medication but most likely his doctor would need to have him intubated and the time was coming sooner. He told me he didn't want the breathing tube. He just wanted to go in peace. I went to get the resident so he could clarify this, and the patient was officially made DNR/DNI.

Then we really tried working on his pain. We tried more morphine. We tried dilaudid. We tried Fentanyl. It's funny, the resident was so hesitant to up the dose. Each time he would go up in piddly little increments. After going to him for dose adjustments three separate times I finally said, "Look. It's time to stop fooling around here. This man is dying and in agony. I really don't have much experience with opiate dosing and the dying patient but I know we need more morphine."

The resident looked at me incredulously. "What do you mean you don't have any experience with this? You're a MICU nurse!"

"I know, I know, I'm an anomaly. For some reason, my patients don't die. I have never had a patient die on me and I have very rarely cared for a DNR/DNI patient."

He laughed and said, "Well, I'm sticking close to you."

We finally settled on a Fentanyl drip until we could get a PCA pump placed.

And then my shift was over.
I came back the next day and my patient was gone. I asked the night nurse, "So what time did he pass?"
"Oh, he didn't pass. We transferred him to the step-down unit."
Later in the afternoon I snuck a peak at the step-down unit's roster. Amazingly, he was still alive.


So can you see that I need to learn to kick ass?

(Plus - the son was yelling at me to not "knock out his dad" with Fentanyl because the rest of the family was on their way. But that's another story.)

The next time I will know how much to ask for.

I told the night nurse about the events that unfolded during the day, and how we danced around with the opiate dosing and she said to me, "You know what? My first job was in a burn unit. I know how much morphine the human body can take."

I want to have that kind of self assurance and I think the only way to get it is to continue doing what I'm doing.
Even if I have to clean up poo sometimes.