For ethics I have to read two positions on this. Funny thing is is that I have personal experience with this - outside of my role as a nurse.
About 3-4 years ago my mom's good friend Jane (not her real name) - her husband Joe (again not a real name) was walking about 15 minutes from home to go to the local coffee shop (Tim Horton's for us Canadians) where he would meet up with his chums for a morning pick-me-up. He reached the traffic light, pressed the button and when told to cross he did so. Unfortunately at the same time was a young girl who went through the (green for her) light and struck Joe. He was thrown about 15-20 feet and landed in a snow bank. EMS showed up and rushed him to the local hospital. He was stabilized and was discovered to have a massive head injury that required immediate surgery. We live in a (smallish - approx. 75, 000 pop) community that does not have a brain surgeon so he was air lifted to the closest center that could perform this - happened to be in the US. So there he went. Well his wife was notified and off she went to the US to be with her husband. She permitted them to do brain surgery and he was intubated (naturally) and was ventilated for his surgery. The surgery went according to plan and he was brought back to the ICU. He was touch and go for several days and when they tried to take him out of the medically induced coma he would not regain consciousness. He was in an actual coma. He remained this way for several weeks. When he finally DID come out of the coma he was found to have major brain trauma which stripped him of his ability to function - approx. 25% of what he was previously. It took him almost 2 years to be able to even slightly talk (remembered how to curse though which is hilarious) but he had a feeding tube and ended up also needing a catheter. He was wheelchair bound and required support 24 hours a day. He was put into a nursing home for this care but his family also provided for him additional care during the day hours so that his therapists could work with him more personally and often and TRY to regain some function. Then he started to get complications upon complications. This inevitably caused his death. During some part of this his wife was notified that she was NOT allowed to make decisions in regards to his health OR expenses because they had had NOT created a power of attorney, living will or advance directives and so someone else had to make these decisions PLUS she had to go to court in order to get these right given to her (as it should have been).
Because I've seen this and what Jane and Joe had to go through - from this side - and seeing what patients and their families have to go through when these things aren't put into place..... as well as when they are (it's wonderful when they have been). I would like to make it known what I would want or not want.... husband and I tend to disagree on some of it. He would like me to be kept alive (on a ventilator and everything else) so that he could be with me. I on the other hand would NOT want to be kept alive if I were to be incompacitated or diagnosed brain dead.
I had a conversation with my BFF about some of these things and we talked about scenarios because I told her in no uncertain terms that I would NOT want a tracheostomy. Well she made me realize that I would ONLY want it if it could come out - and I would only allow it for 30 days (ever seen the episode of Grey's anatomy - 30 days and that's all I get - if you can't figure it out by then I'm being taking off support) then take it out and if I live then i live - if not I die and I'm ok with that. Clearly I wasn't meant to live.
Now the ONLY time I want to be on a ventilator and kept alive is if I were pregnant and the fetus could be viable and NORMAL (no cerebral palsy due to hypoxemia) then keep me alive until I could "give birth" then take me off life support.
Now if I were expected to live but have some deficits - if I could be expected to be at least 75% of who I was previously (mental faculty wise) then do extradinary measures. If I need antibiotics - please give - I completely agree with them. Don't give him a G/J or any other kind of tube to extend my life. I see enough of this at work and do NOT agree with it. I WANT to be able to drink and eat the "normal" way and if I would die if I didn't have a tube going into my body then that's not the way I would want to live. Again if it's longer then 30 days - let me die! When it comes to tests - do them, do as many as you can to try to figure out what's wrong with me and try to fix it - I'm ok with that - I like tests, it makes treatment easier and WAAAY more effective. When it comes to CPR it's a bit trickier - inately I agree with CPR. However, the longer that CPR is done, the less likely it is that mental faculties will be back to 100% so really, would I want extended CPR?! I suppose I will have to ask a doctor about this to truely know what my answer is to this one. I agree 100% with dialysis and pain medication - I think these things are totally important. I can't think of other things that should be included but I will totally update these kinds of things as I learn and see more.
I think MORE people should put it in writing what they want. And try to think of ANY and ALL kinds of situations.
Showing posts with label ICU. Show all posts
Showing posts with label ICU. Show all posts
Monday, February 3, 2014
Monday, March 5, 2012
Manager's should leave well enough alone!
I'm an RPN (LVN/LPN for those US ppl) and at my hospital we get to practice to FULL scope - which means that we can do ANYTHING an RN can, minus take care of unstable patients.
So on one of my evening shifts I had the privlege of carrying 5 pt's - one where the family is over bearing and there looks like there's going to be legal action taken against the hospital as the family feels that the hospital has caused their mother's stroke (for another post); one pt that is a total care, but she turns really well, and she's a diabetic which means glucose testing and insulin; another pt is independent and only requires 1800 meds. Then I was supposed to get TWO admissions! Now one is enough but two REALLY sucks! And this I knew was going to be the case as soon as I started my shift. CRAP, CRAP, CRAP!!! At least that's what I said in my head.
The ONLY saving grace was that one of the new grad RPN's was going to be shadowing me for 4 hrs. GREAT! And good thing I had her or else I would have been screwed!!! Before the newest patient came up, I took report on the second patient. This is the report for patient number one...
Female in with confusion NYD (not yet diagnosed) and diarrhea. But she was in FOUR POINT RESTRAINT!!! Ok flag number one! Ok, on with report.... aggressive with staff and that's why she has the restraints on. She's on 40% oxygen by mask.... flag number two!! Then I get given her VS - temp normal, pulse in the 90's (okies... sorta), BP normal, O2 of 96% on said oxygen.... but flag number three and probably most worrisome was that her respirations were 40!!!! Yeah this doesn't sound normal... I was told that pt was stable and that there was a referral for a Dr - one that I've mentioned before I had to call in the middle of the night (refer back to my post about my pt with seizures and a back compression fracture). Another issue I had while I took report was that this pt was a diabetic, NPO but only on NS (normal saline) TKVO (to keep vein open)... which didn't make ANY sense because you would think that critically thinking that this pt would become dehydrated since she had diarrhea, was NPO and was a diabetic... ok whatever, I'll bring it up with our MRP (most responsible physician) who would be responsible for this pt - and get her started on D5W at 50cc/hr or something like that. At least that way you are addressing the dehydration possibility AND the diabetic sugar levels.
WELL, when this lady came to our unit, she looked and more importantly SOUNDED terrible!!! I don't know if any of you have ever heard of the "death rattle"... the sound that the chest makes when a person is close to death and aren't swallowing their saliva and these secretions go into the chest and make it sound all congested.... well that's what this lady sounded like. It was crazy - and all of us nurses were like, "why is this patient even coming to our unit, she should be going to ICU"....
The porter, RPN shadow girl and I transferred this patient onto our unit bed and away we went with our assessments. I had the other RPN take the respirations and I would get her BP, pulse and O2 sats.... Again BP was fine, pulse was elevated and O2 sat was 80%!!!!!!!!!!!!! And that was on 40% Oxygen - 8L per minute... MRP was on the unit and I went and grabbed her and had our unit clerk page support (part of our code blue team - which in essense is like me calling a silent code blue) - put the patient in high fowlers and went to grab ventolin and atrovent as well as suctioning equipment. RPN gave us a 40 resp rate and I gave her the suctioning equipment while I set up the breathing treatment. While she was on 100% O2 - during the breathing treatment - her level stayed above 92% - but once we put her back on the 40% she would bounce between 67%-94% sats... the 67% happened often because she was also having periods of apnea and would only breath once you verbally stimulated her.
Once she was stabilized a bit - where she was sitting above 80% sats for more than 5 minutes - I spoke with my UL (unit leader) about what this patient looked like clinically. She asked me whether I wanted someone else to take over. I told her no - that although she was unstable, she was stably unstable and that I felt that I was supported by many people on the unit. I had the MRP there, that if things changed that I have SEVERAL RN's on the unit that could take over, and that support was already paged and I knew what threshold to initiate calling a code. I also indicated that since I had the other RPN, I could stay with this stable patient in a closer fashion than is normal, for our unit.
Therefore I kept this patient... Thankfully I had the other nurse, who then took the initiative to take the blood sugars on the other people, as well as this new pt... and give meds, while I was caring for this new patient pretty much on a 1:1 basis.
About an hour later support came and assessed the patient and then got the other referring doctor to come see the patient and made the decision to put this patient in the ICU - all the while we are ALL in agreement that this patient should NEVER have come to our unit! The support nurse thankfully found a spot in the ICU and put that stuff all in place - without having to go through many hoops that would generally have had to occur and instead it was going to be a trade off. When this patient went to ICU, that I in turn would get an ICU patient back to me (one that was ready to be D/C'd from ICU though). By the time that that happened, I had this patient for almost 3 hours... it was craziness!!!! My lady patient was so unstable that we sent her, not by stretcher, by left her in our bed and wheeled her down the hallway to ICU. With me in tow, ensuring that she breathed.
It was funny bringing her to the ICU because when I gave the nurse taking over, report, she asked me if I would ever consider working in ICU... when I told her yes, she told me to apply for a job. I had to tell her I had to wait another year and a half until I finish my RN, and then maybe I would. I think that this shocked her. LOL
Thankfully I didn't end up getting ICU guy, even though I took report, because I was told that he was quite a handful (had him my next shift and yes he was!!!). Just as I transferred my lady to the ICU, I got my second admit, who although not unstable, was still pretty sick. She was septic and the poor lady had chronic liver cirrhosis and her belly was BIGGER than a lady at 9 mos pregnant - and anyone who reads this and has been to that point - you can totally empathize with her.... sooooooo uncomfortable!!! And her poor legs looked like tree trunks they were sooooo edematous.
Much to my surprise, half way through my shift, when my RPN pal went home, another nurse on my unit helped me by unloading one of my patients - which was UNBELIEVABLY helpful!!! When she did that, she lightened up my load tremendously and allowed me to focus on the unstable patient, but still touch base with my other patients since they were all in the same area and the patient she took was in a TOTALLY different part of unit. Bless her heart!!!
Such a crazy shift! Hope I don't have one of those for a long, long, long time to come! I guess it serves me right since I've had such quiet, easy going shifts before this... I just had a feeling that it was the calm before the storm, and WHAT a storm it was! But I guess it made for a fast and interesting shift and an interesting story for here.
Also - this is being investigated because if the nurse had done her assessments thoroughly, she would have noticed the respiratory distress, should have realized that this patient was NOT suitable for my medical unit, and SHOULD have contacted the physician to indicate this. ALSO, IF the manager of the ER hadn't gotten involved and MADE the nurse call my unit to send this patient to MY unit, the patient could have been given enough time to be assessed by the referred doctor and wouldn't have been sent to my unit in the first place (IMO!). Interesting all the way around!
So on one of my evening shifts I had the privlege of carrying 5 pt's - one where the family is over bearing and there looks like there's going to be legal action taken against the hospital as the family feels that the hospital has caused their mother's stroke (for another post); one pt that is a total care, but she turns really well, and she's a diabetic which means glucose testing and insulin; another pt is independent and only requires 1800 meds. Then I was supposed to get TWO admissions! Now one is enough but two REALLY sucks! And this I knew was going to be the case as soon as I started my shift. CRAP, CRAP, CRAP!!! At least that's what I said in my head.
The ONLY saving grace was that one of the new grad RPN's was going to be shadowing me for 4 hrs. GREAT! And good thing I had her or else I would have been screwed!!! Before the newest patient came up, I took report on the second patient. This is the report for patient number one...
Female in with confusion NYD (not yet diagnosed) and diarrhea. But she was in FOUR POINT RESTRAINT!!! Ok flag number one! Ok, on with report.... aggressive with staff and that's why she has the restraints on. She's on 40% oxygen by mask.... flag number two!! Then I get given her VS - temp normal, pulse in the 90's (okies... sorta), BP normal, O2 of 96% on said oxygen.... but flag number three and probably most worrisome was that her respirations were 40!!!! Yeah this doesn't sound normal... I was told that pt was stable and that there was a referral for a Dr - one that I've mentioned before I had to call in the middle of the night (refer back to my post about my pt with seizures and a back compression fracture). Another issue I had while I took report was that this pt was a diabetic, NPO but only on NS (normal saline) TKVO (to keep vein open)... which didn't make ANY sense because you would think that critically thinking that this pt would become dehydrated since she had diarrhea, was NPO and was a diabetic... ok whatever, I'll bring it up with our MRP (most responsible physician) who would be responsible for this pt - and get her started on D5W at 50cc/hr or something like that. At least that way you are addressing the dehydration possibility AND the diabetic sugar levels.
WELL, when this lady came to our unit, she looked and more importantly SOUNDED terrible!!! I don't know if any of you have ever heard of the "death rattle"... the sound that the chest makes when a person is close to death and aren't swallowing their saliva and these secretions go into the chest and make it sound all congested.... well that's what this lady sounded like. It was crazy - and all of us nurses were like, "why is this patient even coming to our unit, she should be going to ICU"....
The porter, RPN shadow girl and I transferred this patient onto our unit bed and away we went with our assessments. I had the other RPN take the respirations and I would get her BP, pulse and O2 sats.... Again BP was fine, pulse was elevated and O2 sat was 80%!!!!!!!!!!!!! And that was on 40% Oxygen - 8L per minute... MRP was on the unit and I went and grabbed her and had our unit clerk page support (part of our code blue team - which in essense is like me calling a silent code blue) - put the patient in high fowlers and went to grab ventolin and atrovent as well as suctioning equipment. RPN gave us a 40 resp rate and I gave her the suctioning equipment while I set up the breathing treatment. While she was on 100% O2 - during the breathing treatment - her level stayed above 92% - but once we put her back on the 40% she would bounce between 67%-94% sats... the 67% happened often because she was also having periods of apnea and would only breath once you verbally stimulated her.
Once she was stabilized a bit - where she was sitting above 80% sats for more than 5 minutes - I spoke with my UL (unit leader) about what this patient looked like clinically. She asked me whether I wanted someone else to take over. I told her no - that although she was unstable, she was stably unstable and that I felt that I was supported by many people on the unit. I had the MRP there, that if things changed that I have SEVERAL RN's on the unit that could take over, and that support was already paged and I knew what threshold to initiate calling a code. I also indicated that since I had the other RPN, I could stay with this stable patient in a closer fashion than is normal, for our unit.
Therefore I kept this patient... Thankfully I had the other nurse, who then took the initiative to take the blood sugars on the other people, as well as this new pt... and give meds, while I was caring for this new patient pretty much on a 1:1 basis.
About an hour later support came and assessed the patient and then got the other referring doctor to come see the patient and made the decision to put this patient in the ICU - all the while we are ALL in agreement that this patient should NEVER have come to our unit! The support nurse thankfully found a spot in the ICU and put that stuff all in place - without having to go through many hoops that would generally have had to occur and instead it was going to be a trade off. When this patient went to ICU, that I in turn would get an ICU patient back to me (one that was ready to be D/C'd from ICU though). By the time that that happened, I had this patient for almost 3 hours... it was craziness!!!! My lady patient was so unstable that we sent her, not by stretcher, by left her in our bed and wheeled her down the hallway to ICU. With me in tow, ensuring that she breathed.
It was funny bringing her to the ICU because when I gave the nurse taking over, report, she asked me if I would ever consider working in ICU... when I told her yes, she told me to apply for a job. I had to tell her I had to wait another year and a half until I finish my RN, and then maybe I would. I think that this shocked her. LOL
Thankfully I didn't end up getting ICU guy, even though I took report, because I was told that he was quite a handful (had him my next shift and yes he was!!!). Just as I transferred my lady to the ICU, I got my second admit, who although not unstable, was still pretty sick. She was septic and the poor lady had chronic liver cirrhosis and her belly was BIGGER than a lady at 9 mos pregnant - and anyone who reads this and has been to that point - you can totally empathize with her.... sooooooo uncomfortable!!! And her poor legs looked like tree trunks they were sooooo edematous.
Much to my surprise, half way through my shift, when my RPN pal went home, another nurse on my unit helped me by unloading one of my patients - which was UNBELIEVABLY helpful!!! When she did that, she lightened up my load tremendously and allowed me to focus on the unstable patient, but still touch base with my other patients since they were all in the same area and the patient she took was in a TOTALLY different part of unit. Bless her heart!!!
Such a crazy shift! Hope I don't have one of those for a long, long, long time to come! I guess it serves me right since I've had such quiet, easy going shifts before this... I just had a feeling that it was the calm before the storm, and WHAT a storm it was! But I guess it made for a fast and interesting shift and an interesting story for here.
Also - this is being investigated because if the nurse had done her assessments thoroughly, she would have noticed the respiratory distress, should have realized that this patient was NOT suitable for my medical unit, and SHOULD have contacted the physician to indicate this. ALSO, IF the manager of the ER hadn't gotten involved and MADE the nurse call my unit to send this patient to MY unit, the patient could have been given enough time to be assessed by the referred doctor and wouldn't have been sent to my unit in the first place (IMO!). Interesting all the way around!
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