The Most Important Decision

Have you ever listened to someone trying to explain a complex theory--like nuclear physics or aeronautical engineering--and even though you are trying very hard to focus and pay attention, you really don't understand a damned word of it?  Despite your best efforts to grasp the concepts, you just don't have the education or the background to "get" it. 

I think that is what lay people feel like when a doctor tries explaining their loved one's illness and prognosis.  They are tired, scared and confused.  They don't understand what is going on.  They have a terrible hope mixed with a terrible fear.  And they have been raised on a steady diet of television where all health-related issues can be wrapped up neatly in 60 minutes minus commercials. 

Here's what I think:  Doctors should not be allowed to offer expensive, futile, sadistically cruel options to patients or their families.  The doctor is the educated expert; they need to act like one.  The doctor should have the right and the responsibility to say, "Your mom is going to die.  We will keep her comfortable."

That's it.

Too many families are unable to make a reasonable decision when overwhelmed with all this strange, threatening information (cerebral vascular accident, myocardial infarction, pulmonary embolism, septic shock).  Emotions are coming in tidal waves at such a time.  When offered an option, like, "We could trach her..." scared people are going to leap at that chance.

Isn't a "good" person supposed to fight to have their mother live? 

Do you officially become a BAD person if you agree to let her die?

Will you have to wear a placard?

It is an uninformed decision from a lay person.  Ask an ICU nurse if they would want a trach or a PEG tube.  Ask a cardiologist if they want to be coded.  

Requiring the families to make these types of decisions is unrealistic and unfair.  The doctor is the expert.  The doctor should not offer false hope by prolonging the inevitable.  You don't fix the brakes on a car that has been totalled.

How do we make decisions about other serious matters?  In other areas where people's lives and freedoms are at stake? 

We have a system in place that does just that: it's called the justice system.  This is another area rampant with conflict, emotion, massive expense, human suffering and a strong desire to do the "right" thing. 

So, we bring in twelve people.  They hear both sides of the argument, pro and con.  They weigh the evidence.  Then, they vote.

Does the victim get a vote?  No.

Does the victim's family get a vote?  No.

They can be heard, but they don't get to vote. The victim and the family are too enmeshed to be able to make an objective decision.  Everyone understands that allowing them a vote wouldn't be justice.

Is it a perfect system?   Uhhh--no.

Is it the best anyone has ever come up with?   Absolutely yes!

Nurse's Note:  Anybody out there who has a better idea just come right on up and tell us all what it is.   I--for one--would love to hear it.  

That's how our health care system should handle end of life issues.  It would take the burden off the families and give it to an educated, experienced group of doctors, ethicists and nurses. They could review the case, go over all the data and visit the patient and the family.   Then, they would vote on the best hospital course.


Who do you want making decisions about what should be done to you medically?  This group:

Or this one?

Could they be wrong?  Sure!  Anyone can be wrong.  Juries don't make decisions about people's lives based on evidence that is beyond all doubt.  Juries make decisions about people's lives based on evidence that is beyond REASONABLE DOUBT.  "Beyond all doubt" is too impossible of a standard.

Nurse's Note:  Ignore inflammatory comments about death panels.  We don't call juries, "death panels" even though they are making decisions about human lives.  That kind of provocative rhetoric is calculated to foment fear.

As a matter of fact--ignore anything that ever came out of Sarah Palin's mouth.

People say that I'm judgemental.  It's true; I am.  Everyone is.  And everyone needs to be.

Do I have time to get across the street before that oncoming garbage truck runs me down?  It's a judgement call.

Should I wear my purple socks with this mustard and mint-striped halter top?  It's a judgement call.

Should I go on out on a date with a guy who has both eyelids pierced with rusty six penny nails and a skinned kitten hanging from his rearview mirror?   Judgment is REALLY needed here...

It always strikes me as a silly, specious argument when people say, "Who are you to judge?" 

Who am I?  I'll tell you:  I'm a wife, a mother, a daughter, a sister.  I'm a human being stumbling around on this planet sucking in oxygen.  I'm a taxpayer and a citizen.  I'm also a nurse with plenty of first-hand experience.

Saying, "It's not up to me to judge," is like covering your eyes while your house burns down around you. 

Imagine your dog became too ill to eat or breathe adequately.  If you said, "Oh! I just CAN'T let Fifi die!" and had a trach and a PEG tube put in Fifi and put Fifi in bed where she lay in her own excrement, getting bedsores that ooze pus--your neighbors would call the Humane Society.  

You wouldn't treat a dog that way.

What do we remember?  We remember the beginning and the end.  Writers and directors know this well.  When filming a movie, you want a powerful opening scene to grab the audience's attention.  There can be some slow, saggy parts midway, but the end has to be fireworks-phenomenal.  Because when people think about it later, that's what they'll remember.  The beginning and the end.

Do you remember when you met your spouse?  Most people do.

Do you remember the divorce that ended it?  I'll bet you do.

Don't have the life of someone you love end in a nursing home.   Keep your memories sacred, not polluted by the thought that grandpa died comatose or so demented that he was masturbating to pictures of his grandchildren. 

My family knows never to code me and never to put a trach or a PEG tube in me. 

Ever.

Ever.

If they do, they better HOPE I don't get up from that bed.

Insane Childhoods

More children than ever are being diagnosed with psychiatric issues like ADHD, ADD, bipolar disorder, anxiety and depression.  As reluctant as I am to side with Tom Cruise on ANYTHING, it is said that even a stopped clock is right twice a day. 

I do think that many childhood psychiatric illnesses are over-diagnosed and over-medicated.  Here is Camille's three-step all purpose guaranteed fix for whatever type of insanity ails your kid:

STEP ONE:

Throw out all electronic equipment such at televisions, DVD players, Iphones, stereos, video games, Wiis, computers, X boxes, Ipads, gameboys, etc.

 If it has a cord, throw it out.

Nurse's Note:  No child should EVER have a television or a computer in their bedroom. Televisions and computers should be in public areas of the house, not only to encourage togetherness and minimize obesity but to keep your kid off the evening news.

STEP TWO:

Come up with a list of daily and weekly chores that will be expected from your child.  Then, FOLLOW UP on your child's compliance with each item on the list. 

This will require some effort on your part as a parent.  But if you can find the time to take your child to a psychiatrist and give them pills to sedate them, you can find the time to teach them how to work.  Help them learn to be productive and to take pride in their accomplishments. 

Stop parenting chemically.

STEP THREE:

Spend time with your kid.  Most of it should be spent outdoors, in nature.  Play a sport together; go for walks.  Talk.  Tell them about yourself.   Listen to their stories.  Share some of your own.

Nurse's Note:  No child under thirteen needs to have a cell phone.  Save the phone as a special birthday present.  Make it a symbol of adulthood.

Voila!  Now your child isn't crazy anymore!  It's a miracle of modern medicine!!

Dr. PetPeeve

I think that the relationship between physicians and nurses has come a long way over the years.   There is more collaboration now and less opposition.  I work at a teaching hospital, and for the most part, we all get along well together.  

I do, however, have three major pet peeves where physicians are concerned.

The first thing I'm going to bitch about is the computer.

There are 29 computers on the ICU where I work.  When patients are climbing out of bed, call lights are blaring, IV pumps are alarming and a doctor comes and plops his ass down at the computer I'm signed onto, my hand reaches spastically for a large bore needle and adenosine.

Several vials of adenosine. 

My bag and my stethoscope are lying right next to the keyboard in plain view.  What should I read into this behavior?  

Has my touch rendered this ONE computer into a SUPER COMPUTER?  Will orders placed on THIS computer result in a miraculous cure, the patient leaping out of bed, embracing staff, rushing home and donating a quifazillion dollars to the physician?

I guess I can see the appeal.

Or, perhaps the physician is is just too damned self-important to see that I have been working from that very spot all night? 

Move your educated ass 27.9 inches down the desk.  Find a computer no one is using.

Ain't you got no raisin'?

The second thing I'm going to bitch about is IV push pain medication, like fentanyl.  


Too often I see the order, "Fentanyl 25-50 mcgs Q 1 hour PRN".  In some alternate universe where god is a nurse, computers would be wired to deliver a 53,956 joule shock to anyone placing that order.  An white-hot bolt of electricity would shoot up from the keyboard, stopping their heart. 

For good.

If they have one.

In case there are any doctors out there who grew up in a burlap bag prior to residency, here's an update:

Narcotics are abused, so they are tightly controlled.  IV narcotics are VERY closely monitored, checked and cross-checked.  They are watched as obsessively as the waistline of a Bel Air trophy wife.  

Fentanyl only comes in 100 mcg vials.  If a doctor writes, "Fentanyl 25-50 mcgs Q 1 hour PRN", then every time the patient needs pain medication the nurse has to grab another nurse--taking them away from whatever they were doing--drag them along with her to the pyxis, withdraw a vial of fentanyl, pull the drug up in a syringe, waste the appropriate amount in front of the other nurse, have the other nurse sign for the waste in the pyxis's computer, then go give the dose.

Sound complicated?  Time consuming?  Wasteful of not ONE but TWO nurses's time?  It is!  And yet, if you order fentanyl every hour, that little dance must be repeated every hour.  With two nurses.

As a result, many nurses just pull out the vial of fentanyl, give the ordered dose and then put the vial with the remainder of the drug in their pocket or in the bedside server.  They know the patient will want more in about 45 minutes. 

But legally, fentanyl cannot reside ANYWHERE other than in the pyxis, in the patient or wasted down the sink.

This is a perfect example of how bad orders create an environment where narcotics are NOT properly handled because doing the right thing is just so damned inconvenient.   Stop threatening the nurses's licenses! 

If the patient is in enough pain to warrant an order of Q1 or Q2 hours of a controlled substance, order a PCA.  The drug dosages and frequencies can be exactly the same, but it is MUCH less work for the nurse. 

The PCA is set up, the patient gets their little button, the narcotic is secure, the nurses can actually do some work instead of standing in front of a pyxis watching and witnessing fentanyl being wasted, and everyone is happy.  Smiles all around!



Here's my third pet peeve:  verbal orders. 

About verbal orders, I don't like 'em.  

I have once--just ONCE, mind you, but that's really all it takes--had a physician deny that they gave me an order.  It's ugly.  The resident in question gave an order in the night, and when staff arrived in the morning and raked him over the coals his response was to protest that he never told me to do that.  It was all the nurse's fault!  He was innocent! 

That's a pretty serious charge.  "Practicing medicine without a license", I believe it is called.  It all might have turned out badly for me--ending with my children being raised in a homeless shelter--except there were four other nurses involved who had witnessed the whole thing; one had actually taken the phone orders from this dickless shithead when I was in the patient's room. 

All the nurses involved were brought in, questioned, fingerprinted, and waterboarded by our nurse manager, the parking attendant, the state police, the FBI, the CIA, the ACLU, the KGB and the PTA.  We signed statements and held up our right hands and sang songs and pledged allegiance.   

When faced with this avalanche of testimony against him, this asshole--sorry, I meant to write, "doctor"--said that he had been asleep and he must have just forgotten the whole thing. 


I've had physicians protest on the phone that they can't put in an order in because they are busy placing a line or coding a patient.  But, I can read "STAFF LOUNGE"  on the caller ID. 

My trust level with verbal and telephone orders is pretty low.  Avoid the infamous, "He said, she said," cliche. 

Put your own orders in under your own name. 

Rat Poison

Let's talk about Atrial Fibrillation. 

I don't work for a pharmaceutical company, but I am a big fan of warfarin sodium, the drug commonly referred to as, "Coumadin".

Coumadin is frequently prescribed for a condition called,  "atrial fibrillation".  For all you non-medical folks out there, atrial fibrillation--afib--is a disease where the electrical impulses controlling the upper chambers of the heart are erratic.  As a result, the heart's upper chambers--the atria--quiver ineffectively.   Blood isn't pumped well; clots form in the heart.  These clots can break loose and be ejected into the body.

All blood pumped from the heart goes into the aorta.  The aorta is like a SUPERHIGHWAY from the heart; every other artery branches off of it.  

Aortic Superhighway

There are two little arteries immediately off the aorta that feed the heart itself, like back roads that only the maintenance workers can use. 

The next TWO arteries branching off of the aorta go to the brain.  That is where clots being shot out of your heart by its own pumping action are most likely to go.  Your brain.

A clot that travels to your brain and clogs an artery shut there is called a, "stroke".


For those of you who need numbers to be convinced, some statistics:

Afib makes you 6 times more likely to have a stroke.

35% of people with afib will suffer a stroke unless treated.

Afib is responsible for 25% of all strokes

Afib strokes are more major and disabling

23%  afib strokes die (compared with 8% of other stroke etiologies)

44% suffer significant neurologic damage

Strokes in women are more disabling than strokes in men

Coumadin reduces the risk by 60-70%

My sister-in-law has been diagnosed with atrial fibrillation. She is refusing to take coumadin.

Her physician had her sign a waiver saying she understands the risks of not taking coumadin and she is releasing him from all liability.

Nurse's Note: If your physician asks you sign a waiver saying you won't sue him if a bad outcome occurs because you won't take a medication he's prescribed--RIGHT THEN a pulsing neon light and a 57,800 decibel siren should go off in your head. The Solid Gold Dancers should bust out dancing in your living room. 

Take a few minutes and re-think your actions.

Are there risks in taking Coumadin?  Sure!

Are there risks in driving a car?  In cooking spaghetti?   In petting Whimsy?

Every drug carries a risk.  That is what that encyclopedic-length disclaimer inside drug packages are all about.   But, it is a calculated risk.   The risk-to-benefit ratio has been carefully weighed.

Here's a test to see if you should take coumadin if your physician prescribes it.  Rate on a scale of 1 to 5 how valuable these skills are:

1=I hate that!
5=Gotta have it!

Your ability to:

1.  Feed yourself

2.  Get your pants on

3.  Wipe your own ass

4.  Walk to your mailbox

5.  Recognize your family (who IS that ugly old woman?)

6.  Live independently

7.  See

8.  Hear

9.  Bathe yourself

10.  Speak intelligibly 

If your test score was more than 0.3, take the drug your doctor prescribes.

If not--would you consider leaving me your car in your will?

(c) copyright 2012 by the author of this blog. All rights reserved.

The Third Law of Thermodynamics

Dr. Walther Nernst proved with the Third Law of Thermodynamics that absolute zero can never be reached in a finite number of steps.  But, Dr. Nernst was a physicist, not a nurse.  He obviously never had to chart on nursing care plans.  Absolute zero may not be possible with the laws of our universe, but nursing care plans come mighty close.

Nursing care plans are a complete waste of time.  They are double charting, which we vowed to get rid of years ago.   The time I spend charting on care plans could be used doing something useful, like picking my nose or wondering if I need to buy more dish soap on the way home.

Care plans were actually thought up by a fellow nurse!  I hope her PhD was worth it.

 

(c) copyright 2012 by the author of this blog. All rights reserved.