RE: btp's bad habits
06-19-2012, 10:03 PM
Sorry for the girlfriendly cliffhanger. I suppose it wasn't much of a cliffhanger, more of a guy who rented a movie but twenty minutes in has to get off to talk on the phone and just makes everyone sit there.
I suppose the proper thing to do would have been save what I had typed into a text file and finish it up later, but that just didn't occur to me when I heard the door knocking.
Anyway I checked the lady's vitals and they were doing a little better, but still low, like 95/45. But what made me uneasy was that when she said "good morning" to me there was a little gargle in her voice.
Note: I learned later, this means she sounds "wet". Imagine that there is glass of water, and you are drinking this glass of water, and in the middle of drinking this glass of water, you try to tell someone something that it comes out all bubbly.
Now put that glass of water inside your lungs.
Of course, what do I know? I'm just the butt-maid. But I check her oxygen saturation and it comes out at 84%.
LESSON ON OXYGEN SATURATION:
Okay so that's low now.
I go tell the nurse and grab the nasal cannula (little tubes that you wear like a necklace and delivers oxygen through your nose), and I put her on 2 Liters/min of oxygen (a standard starting dose).
Well her number goes up slightly, but right at 90% so I boost it to 3L/m and go talk to the nurse about it.
So, at this point, both myself and her nurse have an idea of what is happening to this lady, though some of the mechanics of it still elude me.
Here's the deal:
Lady comes in dehydrated - so we give her an IV to bring her blood pressure up.
FOR SOME REASON...
...that fluid isn't staying in her bloodstream. It's leaking into her lungs. This is making it harder for her to breathe. After 12 hours of continuous IV usage, that fluid is continuing to accumulate. She is slowly drowning inside of her own body.
So take off the IV?
NO YOU CAN'T. Her blood pressure is still low, we have to keep the IV on to manage the blood pressure. If she drops down to say 40/10 then there isn't anything we can do for her. With a low oxygen saturation, at least we can give her more oxygen.
So we call the doctor and keep the IV running. (also, we don't technically have the authority to remove the IV against the dr's orders. (we should have removed the IV)).
THREE HOURS LATER.
I check her again. Her oxygen saturation has gotten worse, it's back in the 80's again and we can't seem to get it back up past 90%.
WHAT THIS MEANS: The amount of fluid in her lungs has increased SUBSTANTIALLY in the last 180 minutes. She really is starting to drown.
From my standpoint though...I don't really know this for certain. The nurse has called her doctor and while I know that her oxygen stat is down, it's not sending off any major flags for me.
But I know that the dr. has seen her and written an order to have her move to an intermediate care unit. Somewhere they can give stronger medicines that our floor isn't allowed to give.
I figure that we'll get her downstairs, they'll give her medicine to manage her blood pressure, and then take her off the IV and start trying to get that fluid out of there.
Apparently, that was not what happened. Apparently, an hour after we transferred her and moved her into her new bed, and passed report onto the other nurses, she started coughing up a sickly green fluid, the same fluid that had built up and filled her lungs. And she died.
It really wasn't a good day for me. Even though I wasn't there for her passing, I knew what it looked like. I had seen it happen a while back with another patient of mine. It was why her "wet" breathing worried me in the first place.
Before she passed, while she was still on our floor and getting a little worse, I came into her room and explained in a simple way what was happening to her, and why we needed to move her to another floor. I did it in a way that hid my own concerns, my own worries that I weren't certain were substantiated or not.
"Your blood pressure is running low, so we're going to give you some fluid to help build it back up. Right now it's like a waterballoon that isn't filled all the way. We'll come back and check it to make sure it's working."
"Your oxygen levels are a little low. I think it might be related to why you've been coughing and gurgling a little while you breathe. It's nothing too serious, we'll just give you a little extra oxygen to keep it stable."
"Your oxygen and blood pressure are still low, so we're going to move you to another floor. It's over in another building and they can give you some medicine to help your blood pressure that we can't here. The nice thing about over there is that your nurse will only have a couple of patients, so they can pay a lot more attention to you."
"This is your new room. They'll take good care of you here and get your breathing back on track. They'll be monitoring your blood pressure, oxygen and heart rate on this machine right here."
"You'll be okay. I'm praying for you."
I said that last line at a moment when she was already in the new room. The other nurses had left briefly to gather whatever materials or reports they needed and I stood by her side, holding her hand. Earlier she had mentioned how her doctor was a christian, and how that was a huge comfort to her. I wanted to let her know I shared in that, to comfort her more. Something was nagging me to pray with her then, at that moment. But I pushed it aside and ignored it.
That was probably my biggest regret. Not that it would have changed what happened, but that it would have brought her more comfort.
Working at the hospital, you realize that the prayer of choice isn't that a certain patient would get better (though that is what you hope for) but that they would have an easy transition, wherever they go.
---
This is the part where I toss in the tidbits that didn't come up naturally in what I just wrote. Like how, after we moved the patient the nurse showed me that, the only order the doctor wrote (aside from having the patient moved), was a DNR order (Do Not Resuscitate). The nurse was frustrated because "if she's dnr, why did we move her in the first place."
I was mad because "what the hell? That's the order you wrote?" I don't know the whole story or the doctor's perspective, but there have been many times a patient's well being has been seemingly ignored because they're "DNR". It almost seemed that the doctor had simply written that order because he figured she wouldn't make it and didn't want there to be a hassle. But, again, I don't know the whole story, and my secret indignation didn't seem to be shared.
Of course, probably the worst thing I've heard relating to DNR patients was something said to by a speaker at my hospital orientation over a year ago. The person speaking was in charge of a committee designed to oversee "Variances" aka, things that go wrong. She was talking about the various things that warrant a Variance report and then interjected in a callous way that underlied her annoyance:
"And don't fill out a Variance Report for a DNR patient who dies. That's what's supposed to happen."
wow. When a phrase sticks without because of how uncaring it sounds, that's a pretty big clue that there is something wrong there.
The second thing is that, even now, I don't understand the mechanics of what happened to her. She didn't have any known heart disease. She did have acute kidney failure so her fluid wasn't going to be voided out. And I can understand why it would seep into her lungs (and abdomen - it was very distended - though we didn't notice until we transferred her), if her BP was HIGH, but it was LOW. Generally that would mean that fluid would travel AWAY from tissue and back into the bloodstream. It could have been something with her capillaries, but that's rare, it could have been a heart condition, but she hadn't been diagnosed. Really there are several odd things it could have been. And while I don't really /need/ to know it would help if I ever saw this again. again.
I suppose the proper thing to do would have been save what I had typed into a text file and finish it up later, but that just didn't occur to me when I heard the door knocking.
Anyway I checked the lady's vitals and they were doing a little better, but still low, like 95/45. But what made me uneasy was that when she said "good morning" to me there was a little gargle in her voice.
Note: I learned later, this means she sounds "wet". Imagine that there is glass of water, and you are drinking this glass of water, and in the middle of drinking this glass of water, you try to tell someone something that it comes out all bubbly.
Now put that glass of water inside your lungs.
Of course, what do I know? I'm just the butt-maid. But I check her oxygen saturation and it comes out at 84%.
LESSON ON OXYGEN SATURATION:
Okay so that's low now.
I go tell the nurse and grab the nasal cannula (little tubes that you wear like a necklace and delivers oxygen through your nose), and I put her on 2 Liters/min of oxygen (a standard starting dose).
Well her number goes up slightly, but right at 90% so I boost it to 3L/m and go talk to the nurse about it.
So, at this point, both myself and her nurse have an idea of what is happening to this lady, though some of the mechanics of it still elude me.
Here's the deal:
Lady comes in dehydrated - so we give her an IV to bring her blood pressure up.
FOR SOME REASON...
...that fluid isn't staying in her bloodstream. It's leaking into her lungs. This is making it harder for her to breathe. After 12 hours of continuous IV usage, that fluid is continuing to accumulate. She is slowly drowning inside of her own body.
So take off the IV?
NO YOU CAN'T. Her blood pressure is still low, we have to keep the IV on to manage the blood pressure. If she drops down to say 40/10 then there isn't anything we can do for her. With a low oxygen saturation, at least we can give her more oxygen.
So we call the doctor and keep the IV running. (also, we don't technically have the authority to remove the IV against the dr's orders. (we should have removed the IV)).
THREE HOURS LATER.
I check her again. Her oxygen saturation has gotten worse, it's back in the 80's again and we can't seem to get it back up past 90%.
WHAT THIS MEANS: The amount of fluid in her lungs has increased SUBSTANTIALLY in the last 180 minutes. She really is starting to drown.
From my standpoint though...I don't really know this for certain. The nurse has called her doctor and while I know that her oxygen stat is down, it's not sending off any major flags for me.
But I know that the dr. has seen her and written an order to have her move to an intermediate care unit. Somewhere they can give stronger medicines that our floor isn't allowed to give.
I figure that we'll get her downstairs, they'll give her medicine to manage her blood pressure, and then take her off the IV and start trying to get that fluid out of there.
Apparently, that was not what happened. Apparently, an hour after we transferred her and moved her into her new bed, and passed report onto the other nurses, she started coughing up a sickly green fluid, the same fluid that had built up and filled her lungs. And she died.
It really wasn't a good day for me. Even though I wasn't there for her passing, I knew what it looked like. I had seen it happen a while back with another patient of mine. It was why her "wet" breathing worried me in the first place.
Before she passed, while she was still on our floor and getting a little worse, I came into her room and explained in a simple way what was happening to her, and why we needed to move her to another floor. I did it in a way that hid my own concerns, my own worries that I weren't certain were substantiated or not.
"Your blood pressure is running low, so we're going to give you some fluid to help build it back up. Right now it's like a waterballoon that isn't filled all the way. We'll come back and check it to make sure it's working."
"Your oxygen levels are a little low. I think it might be related to why you've been coughing and gurgling a little while you breathe. It's nothing too serious, we'll just give you a little extra oxygen to keep it stable."
"Your oxygen and blood pressure are still low, so we're going to move you to another floor. It's over in another building and they can give you some medicine to help your blood pressure that we can't here. The nice thing about over there is that your nurse will only have a couple of patients, so they can pay a lot more attention to you."
"This is your new room. They'll take good care of you here and get your breathing back on track. They'll be monitoring your blood pressure, oxygen and heart rate on this machine right here."
"You'll be okay. I'm praying for you."
I said that last line at a moment when she was already in the new room. The other nurses had left briefly to gather whatever materials or reports they needed and I stood by her side, holding her hand. Earlier she had mentioned how her doctor was a christian, and how that was a huge comfort to her. I wanted to let her know I shared in that, to comfort her more. Something was nagging me to pray with her then, at that moment. But I pushed it aside and ignored it.
That was probably my biggest regret. Not that it would have changed what happened, but that it would have brought her more comfort.
Working at the hospital, you realize that the prayer of choice isn't that a certain patient would get better (though that is what you hope for) but that they would have an easy transition, wherever they go.
---
This is the part where I toss in the tidbits that didn't come up naturally in what I just wrote. Like how, after we moved the patient the nurse showed me that, the only order the doctor wrote (aside from having the patient moved), was a DNR order (Do Not Resuscitate). The nurse was frustrated because "if she's dnr, why did we move her in the first place."
I was mad because "what the hell? That's the order you wrote?" I don't know the whole story or the doctor's perspective, but there have been many times a patient's well being has been seemingly ignored because they're "DNR". It almost seemed that the doctor had simply written that order because he figured she wouldn't make it and didn't want there to be a hassle. But, again, I don't know the whole story, and my secret indignation didn't seem to be shared.
Of course, probably the worst thing I've heard relating to DNR patients was something said to by a speaker at my hospital orientation over a year ago. The person speaking was in charge of a committee designed to oversee "Variances" aka, things that go wrong. She was talking about the various things that warrant a Variance report and then interjected in a callous way that underlied her annoyance:
"And don't fill out a Variance Report for a DNR patient who dies. That's what's supposed to happen."
wow. When a phrase sticks without because of how uncaring it sounds, that's a pretty big clue that there is something wrong there.
The second thing is that, even now, I don't understand the mechanics of what happened to her. She didn't have any known heart disease. She did have acute kidney failure so her fluid wasn't going to be voided out. And I can understand why it would seep into her lungs (and abdomen - it was very distended - though we didn't notice until we transferred her), if her BP was HIGH, but it was LOW. Generally that would mean that fluid would travel AWAY from tissue and back into the bloodstream. It could have been something with her capillaries, but that's rare, it could have been a heart condition, but she hadn't been diagnosed. Really there are several odd things it could have been. And while I don't really /need/ to know it would help if I ever saw this again. again.