fredericks (![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png)
fredericks) wrote2007-09-13 05:16 pm
fredericks) wrote2007-09-13 05:16 pm
Hard Decisions
One of my patients this past weekend was an older gentlemen with some sort of suspected liver growth. Of course the first thing that comes to mind is cancer. I got him on his second day in the hospital, I believe. My report from the day nurse (the idiot I ranted about in a previous entry) was that the man "looked like death". My next question was whether or not he had a DNR ("do not resuscitate") order in place. No; he was a full code. Right away I was concerned. But I said nothing, took my report, and did my rounds.
When I got to the patient in question he was unresponsive to queries, but did squeeze my hand when asked and then said "thank you" in a weak but discernable voice as he let me go. His blood pressure was on the low side but still acceptable (you learn to not worry about systolics between 90 and 150-160 within reason [no trending up or down]; his was barely on the 90 mark, but the family said his usual is between 90-110), and his oxygen saturation was above 92% on two liters. He was on 100 mL of IVF/hour as well, and his electrolytes and hemoglobin/hematocrit were more or less within normal limits. Things didn't look *great*, but he didn't seem as bad off as the initial report had let me think. I made sure he was comfortable and continued on my way.
The patient's family showed up about forty minutes after my shift started. There were two females and the most vocal member, a rather harried-looked guy who identified himself as the patient's son. I introduced myself to them and they came across as friendly and, understandably, concerned. After half an hour or so the son came up to me and asked me if his father looked "right". I explained that this was the first time I'd had his father as a patient and told him how I'd found him at the beginning of shift. The son nodded through my explanation, then said he was concerned because his father wasn't really responding to him. Bells of the bad variety started going off in my head and I went back to check his vitals again. BP was now around 86 or so, with a diastolic of 50ish, heart rate was in the 90's, O2 sat was...? 86? I cranked the O2 to five liters to get him sat'ing in the 92-93 region, then went to call the nurse practitioner. Mind, I wasn't *too* worried at this point, but I knew things weren't hunky-dorey. I recall I didn't take the patient's temperature but I knew he felt warm. Or maybe I did take it via auxiliary (armpit) and it came back afebrile but I knew that was wrong because he felt like he had a fever. Either way the patient wasn't tachycardic yet - fevers tend to elevate heart rates - so that wasn't a bigger priority than the dropping BP. I called the nurse practitioner and she said she'd come check on the patient in question.
[While this is going on I'm dealing with *another* patient, this one who I was told might have aspirated her tube feed earlier during the day. When I went in to see her she seemed to be breathing rather heavily and had an elevated heartrate, felt feverish, but BP was 110ish over 70ish, and she was sat'ing 100% on 3 liters of 02. The patient with the lowered BP got priority, and while I ran around tending for the first patient I kept an eye on this one. Then all hell broke loose in the form of a hypochondriac daughter. But this post is about the first patient. I suppose I'll speak about THIS patient another time.]
The NP came by and checked the patient's BP, then sort of *looked* at me. I've worked with this woman long enough to know her looks, and the one she shared with me this time wasn't good. She ordered a 500mL bolus of normal saline (a bolus is when you let IV fluid run rapidly into a patient with the hopes of boosting his/her blood pressure) and we pow-wow'ed in the hallway. I'd consulted the medicine the patient received for the day and saw he wasn't getting any anti-hypertensive medication but he had gotten 5 mg of oxycodone at seven in the morning. Usually that'd have been kicked out of a body's system before 9PM, but this guy had a compromised liver. Bad news. The NP called the patient's physician while the bolus was going, to ask whether or not he wanted narcan administered. The physician (a gentlemen who I will henceforth refer to as "The Asshole") refused.
The NP hung up, looked at me again (not quite the FUBAR look, but close enough) and went back to check the patient's BP. Now it was in the 70's. At that point the NP took it upon herself to get a MICU (medical intensive care unit) consult for the patient. The MICU docs, working independently, dosed the patient with narcan...at which point his BP jumped to 110/80 and he started speaking like nothing had happened. It was almost comical how fast he turned around - they injected the narcan and less than a minute later the guy went "oww! leave me alone already". SO, job well done, drama finished. NOT.
[Then, of course, I had to deal with the OTHER patient, the aspirated Peg Feed Lady. Lots of running around with her, lots of dealing with her fucking annoying-as-hell daughter, we called our Rapid Response Team for the patient and her tachy heart rate, she got moved to a tele floor. When I get back from taking her to tele I find the following.]
The son came to me later in the night - this must have been close to 1 in the morning - and told me his father was in pain, asking me to do something to relieve it. The patient's bad physical response to the oxycodone along with the family's discomfort with seeing him in a lethargic state had me relucant to give him anything medicine-wise, but pain is pain and it has to be addressed. When I went in the room the gentlemen appeared restless, but when I asked him if he was in pain he said "no". His BP was in the 90's and his heartrate was in the 80's, and he was sat'ing 94 or so on 4 liters. I called the NP and told her he was written for 2mg of morphine, but I was reluctant to give him that much. She okay'ed 1mg and told me to keep an eye on the patient (to which I said "duh"). The 1mg was administered, BP and 02 sat remained okay, good times. BUT the son came out of the room thirty minutes later and said his father was still restless. We ended up giving him an additional .25 mg, and the NP told me I should just get the family out of the room so they can stop distracting the father and maybe allow the man to get some rest (I didn't, but they left on their own). I think I ended up giving him .5mg more before the family decided to leave and go home at around 2 or 3 in the morning. The patient was otherwise stable during the shift.
ALL OF WHAT HAPPENED WAS TOLD TO THE DAY NURSE. She was discouraged by me from giving the patient any more oxycodone and told about the patient's response to pain meds in general. Why, then, did this woman give the patient 2mg of morphine IVP right before she gave me report at 7PM the next day? When the patient's BP had been in the low 80's at 3PM and she didn't document a BP immediately prior to giving the morphine? Fine, there was no parameter listed for morphine administration (as in, "hold if SBP<90"), but there's something called "using your nursing judgment". There's also something called "having goddamn common sense". I really think she didn't give a shit because she wasn't going to have to deal with the fallout.
And, oh yes, there was fallout. On rounds I went to see the patient and found him moaning in his bed, family at the bedside. He wasn't was verbal as he'd been yesterday post-narcan and he wasn't completely out-of-it, but he didn't look *well*. It's hard to describe it. Those damn bells were going off in my head again. The son came out to see me after an hour to request additional pain medication. The patient wasn't scheduled for any more pain medication (the morphine order was two milligrams every three hours and he'd gotten the dose two hours before, and even IF he was able to get the medication I'd have been reluctant to administer it because of what had happened the day before) and I told the family as much, but on the off-chance that a one-time order of *something* could be approved I went and checked the patient's blood pressure: 71/49. Oh, SO not good. Heart rate (HR) and O2 sat were okay, though, and the patient was still on 100mL of IV fluid/hour.
I called the NP and she (the same wonderful woman I worked with the day before) gave me a T.O. ("telephone order") for a 500mL bolus. I hung the bolus and told the family to call me when the bag was empty so I could recheck the patient's vitals.
[Meanwhile I had MORE shit to clean up for the day nurse, in the form of a patient who was supposed to have been transported to a telemetry floor since 1PM and had been left on our floor unmonitored (without an EKG monitor and with no Advanced Cardiac Life Support staff trained keeping a close eye on him) from 1PM until 7PM, when my shift started. I ended up having to run around to get him off the floor while dealing with the gentleman above. We got him downstairs to a telemetry unit a little after 9PM, which was when the real fun with the other patient started.]
The family came out and told me the bolus was finished. Right at that moment the patient's physician ("The Asshole") called, returning a call the son had sent his way earlier. I spoke to The Asshole briefly, explaining the situation (persistent hypotension, patient's family with request for pain medication, status post bolus), and went to recheck the patient's blood pressure while the son got on the phone. The patient's BP was still in the 70's. Not good. I grabbed another bolus bag and hung it clamped, then waited until the son was done with The Asshole before giving him the run-down. His order? Give another 500mL bolus, then give the patient 2mg of Morphine no matter what the patient's vitals. I glanced over at the son from across the nurse's station, and repeated what The Asshole had told me, just to make sure that I wasn't hallucinating it. The patient was a full code still, meaning if I followed through with The Asshole's order it was pretty such guaranteed that we'd end up sending this patient into cardiac arrest, making a crappy situation that much more shitty. T.A. said "yes, that's what I mean", I said okay, then I called the NP and told her what was going down. The NP huffed on the phone, then said if that's what T.A. ordered I should follow through with his, saying "his orders supercede [her] own".
Now, I was this side of freaked out. The physician essentially ordered me to send the patient into a code situation. And the NP told me to do what the physician said. At that point I took a deep breath and went back into the room with the patient and his family to unclamp the bolus. The son took a look at me and asked me what I thought; his exact words "I think I'm beginning to be able to read your face and you don't look too happy". At that point what do you say? Do you say you think the physician wants to kill his father? That the physician is a bloody insensitive idiot? What I ended up sharing with them at that point was my reluctance to administer the morphine. I told them morphine lowers blood pressure and can decrease oxygen saturation, and the patient wasn't hemodynamically stable to begin with.
At that point he asked me what should be done and I *cringed*, because seriously. The patient was still moaning periodically and the son seemed set on getting his father pain medication, but...do you want your father alive and in pain, or out of pain and, essentially, dead? That statement along with a couple of others ran through my mind as I stalled to come up with something to say. Then the son added "I trust you, I know you'll keep an eye on [my father]". And which point I wanted to scream "I HAVE SEVEN OTHER PATIENTS AND I'VE BEEN IN HERE ALMOST ALL BLOODY NIGHT". Sometimes - most times - families forget that. And it's selective forgetting, too. Understandable selective forgetting. When you have a relative in the hospital you can give two shits about whether or not the guy across the hall needs a transfusion, or whether the lady two rooms down is hypokalemic, or if this gentleman has a fever, etc etc. But the nurse doesn't have that luxury. The son wanted ICU care on a general medicine floor, and it wasn't going to happen. And I didn't want to be held liable. I just took another deep breath, opened up the bolus, explained the effects of morphine again, and told them I'd give the pain medication when the fluid was done.
When I went back to the nurse's station I was met by the NP. She'd had a change of heart, and wanted to see the patient again. I told her I had the bolus going and hadn't given the morphine yet. She went in the room and checked the patient's BP again...then gave me the FUBAR look before telling me to call the Rapid Response team while she dialed up the MICU. The patient's BP at that point? 60/40. The MICU docs descended, the patient got a femoral TLC placed, a non-rebreather face mask in place, and got whisked up to the MICU within 45 minutes. The NP and I spent time cursing out T.A., which was slightly cathartic. I ran into the family again when I went up the MICU to retrieve our cardiac monitor and bed. The son asked me if I thought they'd made the right decision, and I assumed he meant allowing them to take his father to the MICU. I said yes, but really? I was thinking to myself "you need to learn how to let go; make your father DNR". Easy to say, I know.
God. I really needed this vacation.
When I got to the patient in question he was unresponsive to queries, but did squeeze my hand when asked and then said "thank you" in a weak but discernable voice as he let me go. His blood pressure was on the low side but still acceptable (you learn to not worry about systolics between 90 and 150-160 within reason [no trending up or down]; his was barely on the 90 mark, but the family said his usual is between 90-110), and his oxygen saturation was above 92% on two liters. He was on 100 mL of IVF/hour as well, and his electrolytes and hemoglobin/hematocrit were more or less within normal limits. Things didn't look *great*, but he didn't seem as bad off as the initial report had let me think. I made sure he was comfortable and continued on my way.
The patient's family showed up about forty minutes after my shift started. There were two females and the most vocal member, a rather harried-looked guy who identified himself as the patient's son. I introduced myself to them and they came across as friendly and, understandably, concerned. After half an hour or so the son came up to me and asked me if his father looked "right". I explained that this was the first time I'd had his father as a patient and told him how I'd found him at the beginning of shift. The son nodded through my explanation, then said he was concerned because his father wasn't really responding to him. Bells of the bad variety started going off in my head and I went back to check his vitals again. BP was now around 86 or so, with a diastolic of 50ish, heart rate was in the 90's, O2 sat was...? 86? I cranked the O2 to five liters to get him sat'ing in the 92-93 region, then went to call the nurse practitioner. Mind, I wasn't *too* worried at this point, but I knew things weren't hunky-dorey. I recall I didn't take the patient's temperature but I knew he felt warm. Or maybe I did take it via auxiliary (armpit) and it came back afebrile but I knew that was wrong because he felt like he had a fever. Either way the patient wasn't tachycardic yet - fevers tend to elevate heart rates - so that wasn't a bigger priority than the dropping BP. I called the nurse practitioner and she said she'd come check on the patient in question.
[While this is going on I'm dealing with *another* patient, this one who I was told might have aspirated her tube feed earlier during the day. When I went in to see her she seemed to be breathing rather heavily and had an elevated heartrate, felt feverish, but BP was 110ish over 70ish, and she was sat'ing 100% on 3 liters of 02. The patient with the lowered BP got priority, and while I ran around tending for the first patient I kept an eye on this one. Then all hell broke loose in the form of a hypochondriac daughter. But this post is about the first patient. I suppose I'll speak about THIS patient another time.]
The NP came by and checked the patient's BP, then sort of *looked* at me. I've worked with this woman long enough to know her looks, and the one she shared with me this time wasn't good. She ordered a 500mL bolus of normal saline (a bolus is when you let IV fluid run rapidly into a patient with the hopes of boosting his/her blood pressure) and we pow-wow'ed in the hallway. I'd consulted the medicine the patient received for the day and saw he wasn't getting any anti-hypertensive medication but he had gotten 5 mg of oxycodone at seven in the morning. Usually that'd have been kicked out of a body's system before 9PM, but this guy had a compromised liver. Bad news. The NP called the patient's physician while the bolus was going, to ask whether or not he wanted narcan administered. The physician (a gentlemen who I will henceforth refer to as "The Asshole") refused.
The NP hung up, looked at me again (not quite the FUBAR look, but close enough) and went back to check the patient's BP. Now it was in the 70's. At that point the NP took it upon herself to get a MICU (medical intensive care unit) consult for the patient. The MICU docs, working independently, dosed the patient with narcan...at which point his BP jumped to 110/80 and he started speaking like nothing had happened. It was almost comical how fast he turned around - they injected the narcan and less than a minute later the guy went "oww! leave me alone already". SO, job well done, drama finished. NOT.
[Then, of course, I had to deal with the OTHER patient, the aspirated Peg Feed Lady. Lots of running around with her, lots of dealing with her fucking annoying-as-hell daughter, we called our Rapid Response Team for the patient and her tachy heart rate, she got moved to a tele floor. When I get back from taking her to tele I find the following.]
The son came to me later in the night - this must have been close to 1 in the morning - and told me his father was in pain, asking me to do something to relieve it. The patient's bad physical response to the oxycodone along with the family's discomfort with seeing him in a lethargic state had me relucant to give him anything medicine-wise, but pain is pain and it has to be addressed. When I went in the room the gentlemen appeared restless, but when I asked him if he was in pain he said "no". His BP was in the 90's and his heartrate was in the 80's, and he was sat'ing 94 or so on 4 liters. I called the NP and told her he was written for 2mg of morphine, but I was reluctant to give him that much. She okay'ed 1mg and told me to keep an eye on the patient (to which I said "duh"). The 1mg was administered, BP and 02 sat remained okay, good times. BUT the son came out of the room thirty minutes later and said his father was still restless. We ended up giving him an additional .25 mg, and the NP told me I should just get the family out of the room so they can stop distracting the father and maybe allow the man to get some rest (I didn't, but they left on their own). I think I ended up giving him .5mg more before the family decided to leave and go home at around 2 or 3 in the morning. The patient was otherwise stable during the shift.
ALL OF WHAT HAPPENED WAS TOLD TO THE DAY NURSE. She was discouraged by me from giving the patient any more oxycodone and told about the patient's response to pain meds in general. Why, then, did this woman give the patient 2mg of morphine IVP right before she gave me report at 7PM the next day? When the patient's BP had been in the low 80's at 3PM and she didn't document a BP immediately prior to giving the morphine? Fine, there was no parameter listed for morphine administration (as in, "hold if SBP<90"), but there's something called "using your nursing judgment". There's also something called "having goddamn common sense". I really think she didn't give a shit because she wasn't going to have to deal with the fallout.
And, oh yes, there was fallout. On rounds I went to see the patient and found him moaning in his bed, family at the bedside. He wasn't was verbal as he'd been yesterday post-narcan and he wasn't completely out-of-it, but he didn't look *well*. It's hard to describe it. Those damn bells were going off in my head again. The son came out to see me after an hour to request additional pain medication. The patient wasn't scheduled for any more pain medication (the morphine order was two milligrams every three hours and he'd gotten the dose two hours before, and even IF he was able to get the medication I'd have been reluctant to administer it because of what had happened the day before) and I told the family as much, but on the off-chance that a one-time order of *something* could be approved I went and checked the patient's blood pressure: 71/49. Oh, SO not good. Heart rate (HR) and O2 sat were okay, though, and the patient was still on 100mL of IV fluid/hour.
I called the NP and she (the same wonderful woman I worked with the day before) gave me a T.O. ("telephone order") for a 500mL bolus. I hung the bolus and told the family to call me when the bag was empty so I could recheck the patient's vitals.
[Meanwhile I had MORE shit to clean up for the day nurse, in the form of a patient who was supposed to have been transported to a telemetry floor since 1PM and had been left on our floor unmonitored (without an EKG monitor and with no Advanced Cardiac Life Support staff trained keeping a close eye on him) from 1PM until 7PM, when my shift started. I ended up having to run around to get him off the floor while dealing with the gentleman above. We got him downstairs to a telemetry unit a little after 9PM, which was when the real fun with the other patient started.]
The family came out and told me the bolus was finished. Right at that moment the patient's physician ("The Asshole") called, returning a call the son had sent his way earlier. I spoke to The Asshole briefly, explaining the situation (persistent hypotension, patient's family with request for pain medication, status post bolus), and went to recheck the patient's blood pressure while the son got on the phone. The patient's BP was still in the 70's. Not good. I grabbed another bolus bag and hung it clamped, then waited until the son was done with The Asshole before giving him the run-down. His order? Give another 500mL bolus, then give the patient 2mg of Morphine no matter what the patient's vitals. I glanced over at the son from across the nurse's station, and repeated what The Asshole had told me, just to make sure that I wasn't hallucinating it. The patient was a full code still, meaning if I followed through with The Asshole's order it was pretty such guaranteed that we'd end up sending this patient into cardiac arrest, making a crappy situation that much more shitty. T.A. said "yes, that's what I mean", I said okay, then I called the NP and told her what was going down. The NP huffed on the phone, then said if that's what T.A. ordered I should follow through with his, saying "his orders supercede [her] own".
Now, I was this side of freaked out. The physician essentially ordered me to send the patient into a code situation. And the NP told me to do what the physician said. At that point I took a deep breath and went back into the room with the patient and his family to unclamp the bolus. The son took a look at me and asked me what I thought; his exact words "I think I'm beginning to be able to read your face and you don't look too happy". At that point what do you say? Do you say you think the physician wants to kill his father? That the physician is a bloody insensitive idiot? What I ended up sharing with them at that point was my reluctance to administer the morphine. I told them morphine lowers blood pressure and can decrease oxygen saturation, and the patient wasn't hemodynamically stable to begin with.
At that point he asked me what should be done and I *cringed*, because seriously. The patient was still moaning periodically and the son seemed set on getting his father pain medication, but...do you want your father alive and in pain, or out of pain and, essentially, dead? That statement along with a couple of others ran through my mind as I stalled to come up with something to say. Then the son added "I trust you, I know you'll keep an eye on [my father]". And which point I wanted to scream "I HAVE SEVEN OTHER PATIENTS AND I'VE BEEN IN HERE ALMOST ALL BLOODY NIGHT". Sometimes - most times - families forget that. And it's selective forgetting, too. Understandable selective forgetting. When you have a relative in the hospital you can give two shits about whether or not the guy across the hall needs a transfusion, or whether the lady two rooms down is hypokalemic, or if this gentleman has a fever, etc etc. But the nurse doesn't have that luxury. The son wanted ICU care on a general medicine floor, and it wasn't going to happen. And I didn't want to be held liable. I just took another deep breath, opened up the bolus, explained the effects of morphine again, and told them I'd give the pain medication when the fluid was done.
When I went back to the nurse's station I was met by the NP. She'd had a change of heart, and wanted to see the patient again. I told her I had the bolus going and hadn't given the morphine yet. She went in the room and checked the patient's BP again...then gave me the FUBAR look before telling me to call the Rapid Response team while she dialed up the MICU. The patient's BP at that point? 60/40. The MICU docs descended, the patient got a femoral TLC placed, a non-rebreather face mask in place, and got whisked up to the MICU within 45 minutes. The NP and I spent time cursing out T.A., which was slightly cathartic. I ran into the family again when I went up the MICU to retrieve our cardiac monitor and bed. The son asked me if I thought they'd made the right decision, and I assumed he meant allowing them to take his father to the MICU. I said yes, but really? I was thinking to myself "you need to learn how to let go; make your father DNR". Easy to say, I know.
God. I really needed this vacation.