Out

Today was my last day at Sinai.

Neurology isn't what I want to do forever and so I'm excited to move on to the next adventure. For me, this means oncology, something I've wanted to do since my last semester of nursing school.

It seems so long ago that I felt like I was mindlessly clicking buttons and writing the same but slightly different cover letters over and over and hoping for someone to say SOMETHING, even if it was rejection. After six months, I finally had a job. At the time, I had no interest in pulmonary and infectious disease but if they were willing to give me a pay check, I was willing to work for one.

The idea of me being able to move on because I decided I wanted to do something else was unfathomable.

Nursing school friends, it gets better.

On Death and Dying - The Distraught Niece

Recently, I've had a few patients pass away on my shift. We are not a hospice unit; the majority of our patents are admitted for some kind of neurological issue. But we do get other types of patients on occasions. This is one of them.

All of our patients have some kind of order set put in by their physicians. They dictate the frequency and type of vital signs to be taken, when and what labs are to be drawn and what the patient is allowed to eat, if anything. There are other orders, but these are the most common ones.

All patients are required to have a code status, which is perhaps the most important one. At any moment, a patient could stop breathing and we need to know what to do. If we have no information, the default is full code and all appropriate interventions are used as necessary. This may include CPR, oxygen therapy (intubation or an external mask), medications, etc.

For patients who want no interventions in the event that they stop breathing, our facility uses AND - Allow Natural Death. A more common term used at many other facilities is DNR - Do Not Resuscitate, but the meaning is the same.

The first of these patients came to our unit from the ICU as AND. She was elderly and non-responsive. The orders for her were comfort care only. This means that, among other things, no vital signs are ordered. Many times, as was the case for this patient, pain assessments were ordered at regular intervals and a constant morphine drip was running. When she arrived, the charge nurse, tech and I went into the room to set her up but unlike other patients, there wasn't much to do. We set her up comfortably in the bed and left her to rest.

The charge nurse didn't say it, but he didn't have to - take care of the patient and let him know when it was over.

There were no family members in the room for most of her time there so my hourly rounding was uneventful. The patient arrived with a breathing pattern that is called Kussmaul. It describes a breathing pattern that is one sign that death is near. It's a shallow kind of breathing that sometimes will skip a breath. You learn about it in nursing school and it's hard to describe but when you finally hear it, it's very distinct and you know what it is.

Eventually, some family did arrive. Her niece came along with her husband. The niece was in tears over the bedside, while her husband stood a foot or so away from the bedside and calmly introduce himself to me. I left the room and not half an hour later, I was told there was an emergency in that room.

Now the only irregular breathing pattern belonged to my patient's niece. In tears, she asked me if I was absolutely sure there was no pulse. As a nurse, I'm not allowed to pronounce someone dead; that responsibility belongs to the physician. At her request, I hooked up a vital signs machine. The error messages on the screen seemed both comforting and frightening to this woman.

The physician arrived and shortly thereafter told the family she had passed. He asked me to do an EKG (also known as an ECG - electrocardiogram. EKG is its German abbreviation and is sometimes used to differentiate it from similar-sounding procedures like EEGs). The print-out showed the expected straight lines where a heartbeat would have been a few hours ago. Was an EKG necessary? In theory, no, absolutely not. There was not even the slightest indication that this woman might be alive.

But one thing they often fail to address in school is that you don't have just one patient. If there are family members or friends at the bedside - they are just as much your patients. This niece needed that visual to give her some closure.

For her, yes, the EKG was absolutely necessary.

Patient Quote

"Sorry about all of that foreskin."

You know you're a nurse when hearing that is just a normal day at the office.

Today I was getting dressed for work and my sister told me my scrub top reminded her of our grandmother's scrubs.

My grandmother passed away before I started nursing school but I like to think somehow she knows I grew up and became a nurse, too.

Clocking In

I walked into work almost an hour early today because that's when my ride could pick me up.

I saw the nurse I gave my patients to last night and thought about asking how they were last night but then I thought, "She can tell me at 6:54."

Incompetently Competent

One thing that frustrates many of my elderly patients is the idea that a time will come when they are deemed incompetent and unable to make their own medical decisions. 

This week I had one such patient but her situation had one major difference - she was perfectly competent. In nursing school, you learn the definitions of orientation in your patients - a perfectly lucid patient should know at least his or her name, date and time. In my facility, we ask if the patients understand their situation as well.

She was 93 and spent most of her life taking whatever various vitamins she took and for most of her life, she was very healthy and what she was doing worked out for her. But now, at age 93, she is sitting in a hospital bed and has been for several days. After refusing most of the recommended and prescribed medical treatment, the doctor covering her ordered a psychiatric consult.

In the three days I was her nurse, I spoke to her son several times. Our first conversation was where he told me she had been labeled incompetent and the decisions were now up to him, as he was her power of attorney. I had not gotten this piece of news in report from the night nurse but the patient was perfectly willing to tell me all about it. Repeatedly. Loudly.

Curious, I took a look at this note. What led the psychiatrist to this conclusion was firstly, that she was refusing all of her medications and treatment. Secondly, when he or she asked the patient about what the doctor said, all she would say was what she wanted and how everything she had been doing had been working her whole life and that nothing needed to change now. 

This woman wanted to go to rehab. Everyone in her family even remotely involved wanted her to go to rehab. Unfortunately, her blood pressure, even done manually, often registered in the 200's. All of the physical and occupational therapists on my unit take blood pressures before working with patients and they always call me when patients have blood pressures like that. Until the blood pressure is controlled, they won't work with them because they don't want to take the risk of causing a stroke. A rehab doctor deciding whether or not to admit her to a facility will have similar guidelines.

Over and over, we all heard about how her blood pressure has always been this high and that there is nothing that can be done about it. Furthermore, she was focused on getting a psychiatric re-evaluation to prove she was competent. But for her, the psychiatric consult was only relevant to her pride. The ultimate decision was rehab. The patient wanted rehab. The doctors recommended rehab. Her family wanted her to go to rehab. The exact decision she wanted would be made no matter who was officially making it. Honestly, it had already been made: the only thing holding her back was her refusal of medical treatment.

Some of her friends came in and wanted to provide the hospital with information about labile blood pressure that was supposedly supported by the American Heart Association (which may have been true and I would have been more than happy to read such studies) and to sue the hospital for deeming her incompetent.

I haven't had a very long career. I haven't seen everything. I like to think I've seen a lot of things but this is the first time I've seen a patient who is both competent and incompetent.

Last week, you demanded I find your NPO husband a shrimp sandwich.

This week, you have requested he be on the kosher diet.

Don't think I didn't notice the empty McDonald's containers ALL OVER THE ROOM!