Tuesday, May 31, 2011

geneva dreams

I want to make it clear: one, I do not think poorly of floor nurses, though part of this blog entry may indicate that. Rather, I wish to underline the strain they work under, and how goddamn hard their job is. I would make a terrible floor nurse, myself; big ups to the nurses that do it. Two: I have known amazing, brilliant, compassionate physicians; so, physician friends, please don't be offended if it appears that I'm bashing your brethren. I just tend to have bad ones in the stories I tell.


Report from Innocent Floor Nurse, 0740: "Patient, 89, male from Local Area. Admitted for shortness of breath, found to have pneumonia. I've taken care of him on and off for a couple of weeks, and he was living independently prior to admission. He's deteriorated over the last couple of days. His O2 requirements have gone up. He's now on eight liters nasal cannula." (I stifle a snort here. A regular nasal cannula is useless for anything beyond six liters.) "Significant history includes COPD, extensive cardiac issues (I don't know all of it, sorry; it's a lot, though), rheumatoid arthritis, and prostate cancer."
I butt in here: "Is he a former smoker? Is the CA a current concern? Does he still have a prostate?"
A pause, then, "Uh...I don't know. Sorry. Anyway, did I mention his RA? He doesn't complain much of pain, but it's made his PulseOx readings impossible because his hands are in such bad shape. According to that, he was satting in the 70's." (A normal read for someone in decent respiratory status: 92-99%.) "RT thought that was accurate. They got one of their portable readers and got the same readings."
"On his fingers?"
"Yeah. He was struggling to breathe, so we turned up his O's. At that time, he stated that he was 'ready to go', and that all his affairs are in order. He asked for the doctor, so we called in Dr. Golf. We made him a DNR per his wishes."
Me: "Oh? Okay. Two questions, then: one, how is his family coping, and two, why is he coming to the ICU? He's a Do Not Resuscitate. We resuscitate people here."
"Well...okay, I don't know. But DNR doesn't mean 'do not treat'. And he doesn't have a family. Oh---he's been hypotensive, too. I haven't given him any of his blood pressure drugs."
"What are we treating? End-stage Everything? Look, I know you're not driving here, but...why are we doing this? Shouldn't we just give this guy a buttload of pain drugs and a quiet room? If he's with it, he knows what he's asking for, and there's no one around to fight it, this seems like the wrong place for him."
"I know, but...I have seven other patients. Can you take him now? We're not supposed to have patients out here on more than six liters."
"Yeah, sure. Bring him to room X."

And ten minutes later, I meet my pink, warm, dry, in-no-distress patient that's ready to meet his Maker.


Patient turns out to be a really nice guy; neurologically intact, cultured and educated. Very funny for someone whose body was busy betraying him. He makes me promise that I wasn't going to do anything extraordinary to save him from the inevitable. He even went down a list: "No CPR, no artificial breathing, no feeding tube with artificial food...although I do want water...and I don't want any more pain." I told him that my goal was to make him as comfortable as possible. Throughout the morning, I talk a couple of times to Dr. Consulting about Patient.
"I don't get it. What are we doing here? Shouldn't we talk to the Palliative team about him?"
"Probably, but he's not my patient. Besides, just because he's a DNR doesn't mean we don't do anything for him."
"I know that, but that means treatment of symptoms up to what the patient wants for comfort. This here"---I gesture wildly with both arms around the ICU---"isn't what he was asking for."
"Not my patient. Have you talked to his primary?"
"No. He signed the order and went out of town."
"Hmm. Well. I'm starting some Albuterol for him, as well as some Lasix. He needs to be IS'd" (a respiratory exercise) "so his pneumonia resolves."
"Sure. Makes sense."

He falls asleep around 1230. While he naps, his blood pressure varies from the 110's to a low of 76 systolic. When I go to wake him periodically, his mentation is still intact. I decide not to do anything about the pressure. Trista, the charge nurse, is getting kind of antsy watching his vitals fluctuate.
"Are you gonna call his doc?"
"His pressure's in the low 80's right now."
"You're not worried?"
"No. He's totally with it, he's peeing, he's completely asymptomatic. And he's a DNR. He wants zero interventions, minus pain meds."
"That doesn't mean 'do not treat'."
"What am I gonna do, start Dopamine on him? That's an intervention. Pretty sure he doesn't want it. Besides, he's got one peripheral IV, and that's it." (For the layman: drugs meant to support blood pressure should be administered through a central line. Peripheral IVs are destroyed by this type of drug.)
"There's nothing wrong with that."
I decide it's time to look too busy to talk.

1700: I wake Patient and ask him if he's hungry for his dinner. "What time is it?", he asks, squinting at the clock.
"Five p.m., Wednesday evening."
He gasps. "And...I'm still alive? I didn't expect to wake up!"
What do you say to this?
What I choose to say is: "Yes, you're still alive. Did you not expect to be?"
It turns out, he didn't.


The Palliative Team's nurse arrives as I'm trying to figure out how to tell Patient that naps weren't normally fatal. Gratefully, I ask her to find me after she's done interviewing him. She comes out 15 minutes later, and what she says utterly floors me. "He thought we were going to give him drugs that would kill him. He thought we would assist him with suicide."
"Yeah. That's what's going on, and that's why he's surprised he's still around."
"DUDE. I can't just throw him in the Suicide Machine! This isn't Switzerland."
"I know. I'm going to make a call to his primary, and see if we can get him transferred someplace more comfortable. We'll get him some better drugs so he doesn't hurt." I think about the air hunger this poor guy is going to experience as he drowns in his own body. "Yay for drugs. I like it. Thank you. I've been beating my head against a brick wall all day with this." She smiles and goes to make her phone call.

She returns to my desk a few minutes later looking dismayed. Her voice stays controlled as she relates the bad news. "I just talked to Dr. OnCall, since Dr. Golf is out of town. OnCall says that since he's never met him, he's not comfortable giving those kinds of orders. So Patient's going to stay here unless your unit needs a bed for a critical patient. You can give him one milligram of morphine every three hours."
"One? I sprinkle that on my Corn Flakes every morning so I can cope. That's not gonna touch him."
"That's all I can get for you."

Just because someone's gonna die, it doesn't mean 'do not treat'. Right?

I give a halfhearted report to Kesler; I don't even bother expressing my disgust. Kesler writes and stays silent for most of it, but finally goes nuts at the pathetic morphine dosage, slamming his pen down and making the Manson Lamps at me. "ARE. YOU. KIDDING. ME?"
"I don't make that shit up."
"That's not anything! Oh my God, I am going to call, and call, and call that doc. He's gonna be tired by the time I'm done with him."
"Good luck. Anything else you wanna ask me?"

Like, do I wish this were Switzerland?
It's 7:45 pm. I'm not answering that.