Call A Code

the long drive

2009-04-06T15:11:00.000-07:00

I passed another test today.

I have a long drive to get to my test. And depending on which city i go to take it, I pass a graffiti picture that always gives me a little boost of enthusiasm first.

"It can get better"

I know it's simple and despite the fact that it is actually an anti government meaning, I find encouragement from it.

For now I will be bounced among departments, with the belief that it will get better. And when I don't feel like studying and I'm tired from work and the kids, I have to remember that only I can make it better for myself. I will not only enable the change to take place, but initiate it.

Thank you anarchists/graffiti artist, for my glimmer of hope.

How could you not know she has cancer?

2009-04-06T10:20:00.000-07:00

I imagine this happens everywhere: a patient with no PMH gets admitted, is diagnosed with metastatic disease, and dies within days.

What's even more interesting is the fact that most of those patients look like they are damn near dead to begin with.

I can think of three pt's within the past few weeks alone. One with bone ca, one with lung ca, and one with breast ca. All walked into the ER for some nonspecific pain (shoulder, etc) and ride out in a hearse shortly thereafter.

A few weeks ago I cared for a patient who looked like she belonged in a coffin more than a hospital bed. She was pale, cachectic, and minimally mobile. She just lied in the bed, sleeping away the shifts. I would often watch her breathing for a long time because her visual appearance alone was not enough to reassure me she was alive.

Giving report in the morning the nurse receiving her said, "You know when she gets the diagnosis she will die within days."

I agreed, commenting that she would maybe last a week at best.

I was wrong. She lasted two hours. She got the news, then we coded her because of course she had no PMH therefor never had a need for advanced directives. The code was unsuccessful obviously and the family was called.

They came in for the first time since she was hospitalized nearly a week ago, shocked and outraged. There has never been a think wrong with aunt Sally, how could she just die so suddenly?

I stood there in shock myself.

How could anyone not know she had cancer?

Most of her family died from cancers. She was essentially a bag of bones wrapped loosely in wrinkly skin. The minute she walked in the door she was diagnosed with everything under the sun. And that even excludes cytology diagnoses.

I couldn't think of anything to say in that moment. Another nurse stepped in to help them.

I rendered myself useless and walked away.

I still don't get it. How can one have a family member decline so much and present so many s/s of everything, yet think nothing is wrong. Never tell her to get checked out. Never have the smallest idea that she might have some pathology in her. I just don't understand.

But in the end she passed quickly. No chemo. No radiation. No surgeries or prolonged intubations. She lived her whole life without daily medications or medical interventions.

And as angry as it makes me to see how simple tests could go a long way, I realize that what is really making me angry is that I have a close family member who is aunt Sally a few years prior to her death.

Props for ER finale

2009-04-06T10:10:00.000-07:00

Not being a faithful viewer of ER, I was surprised to see how uneventful and "normal" the episode seemed compared to past episodes. Lost on the Floor recently blogged that he loved the uneventful ending. I thought for sure that the whole hospital was going to explode and nearly everyone would die. And that those who didn't die in the hospital's demise would go work at Dr. Carter's center. How wrong I was. But the notion kept me watching, waiting for the "big one."

Anyway, the one point of the episode I loved was the teen with alcohol poisoning. I'm not that many years out of high school and I know that parents providing alcohol based on the idea "they may as well do it at home than be somewhere else" was common among my own peers. I also know that this practice is increasing rapidly. I think they really took on an important social issue and presented the consequences well.

And I loved when John Stamos said to his daughter that she needs to call if she needs help, no questions asked. That's not something I felt I could do as a teen but it is definitely something my kids need to know I will do for them, no questions asked. It's such a simple idea but goes unsaid way too often.

Clever

2009-04-01T13:44:00.000-07:00

I hate working on Tuesday Nights because then I miss biggest loser. I hate working Wednesday Nights because then I miss Lie to Me. And I hate working Thursday Nights because then I miss Grey's Anatomy.

I never used to have 'shows'. I couldn't have cared less what was on TV.

But now I must find more clever ways to work around this addiction. DVR is the obvious solution, but when I forget to turn it on then I must get creative.

So while Derek proposed to Meredith, I was washing and combing my unconscious patient's hair. She got the full spa treatment, lasting exactly one hour. And I didn't miss a second of the show.

Ending the Interns' Year

2009-03-31T12:59:00.000-07:00

You would think that by now, the interns pretty much have their shit together. It's obvious who wants to be a doctor and who wants an office job aka no patient contact.

But yet there is one intern who should never put his hands on a scalpel because a toothache would end up in a lobotomy. Calling him is always, ALWAYS, a last resort. For patients and nursing staff alike.

Nurse A requests tessalon pearls for a sore throat and cough. An EKG, Chest XRay, and six sets of vital signs later, this intern declares the patient has a cough and orders carafate. The nurse suggests phenergan with codeine, Robitussin or, um, tessalon pearls maybe, which were all shot down by the intern. Carafate only. I guess we could let the patient cough till they gag, then they'll need some carafate. Great thinking.

Nurse B requests an order for PRBC's per the attending's written orders to transfuse if HH is less than 9/29. An EKG, 2 NS boluses, a laxative order (on an acute GI bleed, genius), and a cardiology consult later this intern says no. Nurse B says you're f-ing crazy and calls the attending at home and Nurse B gets her PRBC order stat. But not after the intern throws in a few post transfusion lab orders such as calcium and mag and a full renal profile. I'm shocked he didn't transfer her to the ICU.

Nurse C requests an O2 order on a patient who is a little snowed from some morphine and is in a nice, relaxed sleep. Cardiac enzymes, Chest CT, Abdominal ultrasound, and a thorough interrogation regarding his brief smoking history 25 years ago, the patient gets 2 liters nasal cannula, only because Nurse C called the surgical intern instead. The patient's sats recovered when the morphine wore off.

And last but not least, a patient asks for some colace d/t recent narcotic use. Nurse D notifies the intern which turns into, you guessed it, a million tests. The order is written as mag citrate and the patient is kept in the hospital 2 days longer because he's shitting his brains out. Attending rounds in the AM and asks, why didn't you ask for a stool softener instead?

Sometimes, I think our patients are better off coughing, anemic, dyspneic but euphoric, and full of shit than they are under this intern's care. Is June here yet???

Do you wipe a lot of butts?

2009-03-25T12:43:00.000-07:00

A young woman comes into the ER with what is essentially a menstrual cramp. She has a long medical history and needs a little reassurance.

I'm giving her discharge papers when she looks at me and asks "Do you wipe a lot of butts?"

Excuse me?

She proceeds to tell me she is a single mother working at the local burger place and feels like she needs something better for her baby. She wants to go to nursing school, she tells me.

I try to hide my excitement as I give her the run down on every local program and what it's all about. I'm not excited because I'm recruiting another fish into this net, I'm excited because she is exactly who I was at her age. A young mother with no future.

I spend almost 45 minutes encouraging her, reassuring her, giving her names, and telling her she can make a change for the better. It is an investment towards tomorrow, I promise her. You will give your baby a better tomorrow by doing this today.

She asks me about my school now, my kids now, and my life now since I went to nursing school.

We get up to leave and her dad gives me a hug. "We didn't want to be here tonight, but couldn't be happier that we met you," he says.

I'm happy she has the drive to change her life. But I warn her that it isn't easy. I spend many nights doing homework instead of playing with my kids. A support system is imperative when you want to quit. And yes, some days I feel like I do wipe a lot of butts. But I do it because I have the license and education and desire to do so.

I felt like I was giving her the pep talk I never got. I hope she gets where she wants to be and I hope she is as proud of herself in the end as I am of myself.

Update

2009-03-09T14:04:00.000-07:00

This week we are all pleasantly welcomed with the sight of DOH inspectors as well as the sounds of really pissy managers. Whatever.

The good news: When someone decided to smoke a joint with an oxygen cannula in their nose we learned (pre-inspection) that none of our fire alarms work. That's right: Zero. And half the code bells don't work either but we're used to that.

The bad news: He didn't get to smoke his joint...something about burning and fire and singed hair. I don't know.

What have I been doing? I've been taking test after test and am almost done my next degree. I've also been taking the time to travel with my coworkers, friends, and family. I live central to some of the most interesting places in this country yet never take the time to visit.

So that my friends, leaves me with one final tip for the day: Don't smoke pot with oxygen tubing in your nose.

Never had a thing wrong with him

2009-02-25T11:47:00.000-08:00

A man was admitted for pneumonia. He was in his 90's with absolutely no PMH. All of his organs are intact, he doesn't get vaccinated. No family doctor, no home meds. You know the type.

I get report from the day shift nurse that the attending ripped him a knew anus because he felt he wasn't notified in a timely fashion that the second and third sets of enzymes were positive. Both sets showed up on the computer system at the exact same time, says the day shift nurse.

The doc says the nurse failed.

The doc writes no new orders and leaves after a very public tongue lashing regarding the "nurse's negligence."

The lab is supposed to call when troponins are high. The first troponin was in the 30's. The lab failed.

The second troponin was in the 50's. Again, the lab failed.

Back to night shift. I receive report from the nurse who is bitter and can't walk out the doors fast enough.

I draw new enzymes and the troponin is now in the 60's.

The intern steps on the floor and we are in agreement: they all failed. The pt had T wave changes in the ER, along with chest pain, and the pneumonia seemed to be more of a coincidental finding. However, the doc dropped all of the chest pain and EKG changes part of the admitting diagnosis and admitted him with plain old pneumonia. Whoops.

The patient was informed that he had an MI.

At first he was okay. His enzymes dropped and then spiked again before morning. He became increasingly anxious.

I've never had anything wrong with me, he tells me.

Cardiology sees him the next day and decides that 90 year olds get medically managed.

The patient was discharged s/p myocardial infarction. Determined to live life to his fullest, he went back to his farm to live his simple life the way he done for the past 90+ years.

Medically managed, he died the next morning.

There is nothing you can do for her here.

2009-02-04T00:19:00.000-08:00

The medic reports off to me in the ER. The patient is 95 years old and was here yesterday...for back pain.

"I know there is nothing you can do for her here," she tells me. "But when the EMT's took her home after she was discharged yesterday, they helped her to the bathroom. That's where we found her this AM. She hadn't moved in 17 hours."

Her words stuck with me. My gut was telling me there was more to this story; more to this patient.

"Thanks," I reply.

"Her daughter is here and can provide you with a little more information."

Oh great. The patient is sleepy and not quite as oriented as I would have liked. And by the way she's covered in 17 hour old piss.

A frail old woman came wobbling back the construction corridors and sat in the chair across from my patient. I couldn't help but think this lady looked more like the patient than the pale, sleepy patient lying on the stretcher.

I introduced myself to her and she responded that she was in fact the patient's daughter. I stood quietly, attempting to hide the calculations in my head. Obviously, a woman in her 90's is quite capable of having a daughter who's pretty old herself.

"Her back hurts and I can't take care of her anymore," says the daughter. Understandable, I think to myself. She can barely coordinate the movements of her own legs next to her worn, wooden cane let alone care for another human being. "I don't care what you do with her, but I hope she stays overnight. She can't come home."

Within the next hour the wobbly old woman disappears from the ER, minus her mother.

My gut still tells me this isn't all about back pain. The medic gave me picture-perfect vitals in report...but I will check them hourly. I fail too often because of not following my insticts, I will learn to trust myself.

She's hypertensive and her HR is 40. A stark contrast to the medic's report.

She of course is not ordered a monitor or EKG...she is here for back pain and presumably dementia.

My gut tells me to put her on the monitor and get an EKG. I will not document it so she cannot be charged and I cannot be reprimanded later.

An ER doc is sitting at the chair next to the monitor when he sees the rhythm he jumps from his seat.

"Let me see that EKG!" he shouts.

I've done the EKG and I know the interpretation. I know that she will be transferred to the big hospital. I know that her daughter would be happy that she's not coming home tonight.

"I'm not done putting stickers on it yet," I apathetically reply.

"I don't care about stickers, I want to see it."

"I only have one more."

He huffs.

"The suspense is killing you."

"Third degree heart block! She came in for back pain and I find out she's in a complete heart block!" His arrogant smile induces tiny bits of vomit in the back of my throat. "They don't pay me enough for the work I do here. I'm a genius. Who ever would've guessed she was here for something other than back pain? Where's her daughter?"

"She ditched Mom long ago, genius."

He looked at me skeptically.

"I'm just agreeing with you."

Calling the Code Again and Again and Again

2009-02-03T12:51:00.000-08:00

An old man lies in the ICU right now. He's vented but awake, AO3. His ex-wife stays at his bedside relentlessly.

I would bet every dollar I have on the fact that within the next 6 hours he will code. Why would I do that?

Because he has coded 10 times in 2 days.

His ex-wife, as his only family, has requested he be a full-code each and every time. She watches each compression. The code bells go off so often these days other patients believe it is merely a phone ringing. The code bells go off so much we don't even wait for the room anouncement, we know who it is and where he is.

He is asystolic. Again.

My fellow nurses cry out in anger and sadness that anyone would be put through this torture.

The medical students and residents groan because little "work" can be done between codes.

He is a full code each time....each time he gets compressions and meds and bagging, and you name it.

Each time he recovers. A little worn and a beaten from the events preceeding this alert state. But he's awake and listens intently to the fact that he has been revived, again.

Nurses stopped responding to his codes long ago. It doesn't take many staff to compress and push meds. Deep down inside, they find it unethical and cruel to code him over and over again.

Each time my hands sink inches into his chest and I watch my compressions on his ECG, I am baffled by the science. There is no room for emotion. How can a human body sustain so much trauma induced from a code? How many times can a heart give up before it won't be revived anymore? And if it is so strong to be revived 10 effing times, why can't we believe he may walk out of this ICU one day?

Putting the stress and the emotion beside, I am amazed to watch his case night after night. Prior to coding these 10 times, he has coded several others...about 15 times in all. The nurses want this madness to stop. We keep the ex-wife in the room for each code so she can see his pale chest being manipulated back to life.

But my curiousity lingers. Most patients or families don't make it past one code, let alone 10+. How many times can we call a code for one person? Not a game of numbers, a game of endurance.