Feeling like a POS...

[brandtrn]

Yes, I actually CALLED IN SICK tonight! Can you believe it? I still can't...I NEVER call off, but I've managed to catch SOME kind of creeping crud from a co-worker over the past weekend (said co-worker has called off for the past TWO nights in a row!), and I've got a splitting headache, body aches, fever (the last I checked, it was 100.9 -- not alarming, but high enough to consider myself as potentially infectious!), a sore throat, constant cough and chest pain, and I'm full of freaking SNOT on top of it all! Yes, I DO believe, even though I had that freaking mandatory flu shot last month, that I do have the freaking flu! So yes, I DID freaking call in, and I've been feeling guilty about it ever since. Why feel guilty? Well, because they barely have enough nurses to staff that freaking place when things are going WELL! As insane as the past couple of nights have been, I KNOW that my co-workers are struggling, since I'm not there to help!

I went in to work last night, and YES, I was sick even then, although not running a temperature, so according to policy, had no "real" reason to call off. Let me tell you, there was much fun to be had (and yes, I'm being sarcastic!). One of the people I was responsible for, a spinal surgery patient in her early 70's, had been bradycardic (i.e., she'd had an abnormally slow heart rate) ALL FREAKING DAY LONG, according to the report I'd received from the day shift. What was done?? Well, not much...except that she was dosed with multiple IV fluid boluses (WTF??? Are we gonna overload someone with fluid when their "pump" isn't working properly?? What kind of Doc gives orders like THAT, and what the Hell kind of nurse actually CARRIES THEM OUT?). Anyway, I did my nursing assessment on her at about 6:30 p.m. yesterday, while my CNA was taking vital signs. She informed me that the patient's heart rate was 48, according to the Dinamap (the machine we use to take vital signs on patients). Well, since I'm a nurse with a bit of OCD, and ANY time I get information like that which I DON'T like, I want to verify it...I'm one of the "dinosaurs" in my profession -- if I don't hear the s**t with my own ears, it ain't happening! So, I proceeded to take an apical pulse on my patient (for those of you who don't know what I'm talking about, an apical pulse is taken by pressing the stethoscope to a patient's chest, listening to the heartbeat for a full minute, and actually COUNTING those beats), and got information which pleased me even less...the patient's heart rate was 40, not 48! Since our hospitalist was still in house at the moment, I hightailed it straight to her office, and informed her of my findings, as well as of the patient's complaints of feeling "dizzy" (not unusual with bradycardia). The Doc replied, "well, her heart rate has been in the 40's all day, but she's been asymptomatic." REALLY??!!?? You've been pumping her full of fluids because her BP and urine output has been low, but she's been "asymptomatic??" Are we going to freaking wait for her heart to STOP before we actually decide to DO something about it?? Trust me, I was a bit irate, and wanted to DO something about the problem, because I ALREADY was having a very bad feeling about this s**t! After twisting the Doc's arm a good bit, I managed to get her to order a few labs, which I drew right away and sent out immediately.

Things went from bad to worse from there, though. In report, I'd also managed to glean the information that the patient had been confused the previous night and that they'd needed to set the bed alarm on her. There was NOTHING in the patient history indicating dementia, by the way, but I noticed that, among her home medications, she was regularly taking Seroquel (an antipsychotic) and Xanax (an anti-anxiety agent). Obviously, the poor woman had some kind of early dementia going on, and, judging from her behavior during the night (even though she was reportedly quite appropriate during the day), she probably has a bit of "Sundowner's" going on. Going through her chart with a fine-tooth comb, I saw further diagnoses of "valvular heart disease" and "abnormal brain CT scan" on the consultation notes made by the woman's cardiologist prior to her surgery. WHY was such information omitted from her patient profile (i.e., the patient medical history which nurses can access readily from the computer)? I was only able to glean this information after I'd been taking care of this patient for HOURS, wondering why the eff her behavior was as off the wall as it was! Oh, but I DID have fun!! This patient's bed alarm was going off CONSTANTLY, usually after I had just left her room and was tied up in another room TRYING to care for another patient! One time I responded to the alarm, I found that the patient had crawled over the bedrails, had stripped herself naked, and had pulled her Foley catheter apart from the drainage bag, leaving the system WIDE OPEN for any kind of infectious agents to enter! I found her wandering into the hallway, with the catheter tubing dangling uselessly from her nether regions! Needless to say, as much as the Doc wanted that cath left in to measure urine output, the system had been contaminated, so it had to go! Unfortunately, the patient was NOT in the mood where she was cooperative re: having another system inserted! Oh, well, such is life! The NEXT time the bed alarm went off (while I was in the midst of assisting another patient to the bathroom), I got to the patient room only to find that she'd disconnected her IV tubing from her IV catheter, and found her wandering again, this time dripping blood from her disconnected IV line! There were literally PUDDLES of blood on the floor! Honestly, the minute I'd manage to get the patient (and everything else) cleaned up and the situation supposedly "settled down," and ATTEMPT to care for another patient, the alarm would go off yet AGAIN! WTF??!!?? Our aide had called in sick for the night, there were only TWO nurses in house to care for five patients, one of whom had gone into rhabdomyolysis following knee surgery (damn those freaking statins, anyway!) and needed almost constant monitoring, and my little lady, who was off the wall behaviorally and who was a cardiac disaster just WAITING to happen!

I finally got frustrated enough with our inability to deliver decent care under such circumstances that I called our unit manager, telling her that she had to get SOMEONE into that building to monitor my patient on a one-on-one level, since my being tied up in that room constantly was compromising care for our OTHER patients! Initially, I was informed that I'd have to give my remaining patients to my co-worker nurse (WTF??? This is a nurse who is NEW to our building, has JUST gotten out of orientation, and SHE was the one dealing with our rhabdo disaster!). I told my manager that this was impossible, because my colleague had her hands full and needed help, herself -- and that, as charge nurse, I wasn't capable of helping her, because ONE patient's safety was being so severely compromised! To her credit, even though she'd been working throughout the day shift, when SHE couldn't get anybody else to come in and help us, she came in and did the one-on-one care, herself! Bless her heart! I don't know too many other nurse managers who would even consider doing such a thing! In any case, not only did she free me up to care for my other patients, but she also allowed me the time I needed to contact the Doc on call (since our hospitalist was so unhelpful) re: my patient's condition. As active as she was, her heart rate actually dropped down into the mid 30's while all this crap was going on!! Bad news, that -- yes, the REST of her vital signs were fine (systolic BP was even in the 130's), O2 sats were normal, etc., etc. BUT...her urine output had slowed to practically NOTHING, in spite of the fluids being pumped into her! Yes, I got on the phone with our freaking medical director, since the hospitalist was not only NOT answering calls, but the message I received said that her voice mailbox was "full." WTF?? And all I got from the medical director was orders for a "cardiologist consult first thing in the morning." Again, WTF???

The corker to all of this was when our hospitalist called at about 6 a.m., wanting an update on said patient (even though she couldn't see fit to answer my calls during the night). I gave her a thorough, detailed report of what had transpired during the night, the ever-slowing heart rate, the increased confusion, and the diminished urine output. WHAT did she order?? IV Lasix (i.e., a diuretic)! Lasix is a fine drug when one has fluid overload (which this woman DID have, given all the IV boluses they gave her yesterday and the fact that she'd gained six pounds over 24 hours), but the s**t will ONLY work if you've got a decent PUMP to get it through your system!! WHAT part of this don't these Docs understand?? I was frustrated enough, by that point, especially after having gotten nowhere with our medical director, that I actually asked her WTF she hoped to accomplish by giving her Lasix?? The woman's heart rate was STILL hanging in the 30's (the normal human heart rate is between 60-100 beats per minute)...yes, her labs showed that her kidney function is normal, BUT -- how long will it STAY normal if those poor kidneys do NOT have adequate perfusion? i.e., the blood has to actually GET to those freaking kidneys in order for them to do their work! Deprive those kidneys of blood (and oxygen, etc.) and you are just ASKING for renal failure! The fact that she wasn't putting out urine and had gained all that weight, coupled with the heart rate, told me that she was in heart failure, already! What do we want to do to our patients?? Set them up for multi organ systems failure??? Lasix, my ass!! I wanted 0.5 mg. of atropine to jump-start that heart and get it beating normally, again! Did I get it?? Eff no, I did NOT! Although I DID find out, when I called in sick and then asked about that patient, that they finally sent her off to a general medical hospital where her heart issues could be dealt with. About damn time, I say!! WHY did they NOT do this after her heart rate had been so dangerously low ALL THROUGH THE FREAKING DAY yesterday?? Grrrrrrr!! As much as I love patient care, WHY is it so difficult for a nurse to get a Doc to actually LISTEN to him/her and to actually ASSESS a patient so that he/she can actually SEE what's happening???

[pilvikki]

that's enough to make you go postal!

and STOP this guilty business! it's not your job to provide extra help, which it is when you're sick. what about your health, does it matter? you'd not let a sick nurse work on your shift, you'd send them home until they're well and you need to apply the same standard to yourself.

you also know that to the admins you're just a body, they don't give a crap about you as long as you keep doing the job of 3 people. should you drop dead in the middle of shift, they'd be really, really upset as there'd be nobody to shove into your slot. that's all. been there, done it.

hope you feel better today!

[Icey]

Yes, get yourself well first Cindy, and as Vikks says, don't feel guilty. The flu, or even a stinking cold, isn't ideal when you're dealing with patients who might catch it.

At our local surgery, one of the doctors's just had a week off work because he had flu-like symptoms and there're a lot of different bugs going round at this time of the year. How can you be expected to do your best if you're feeling lousy or liable to spread something?

Hope you soon feel a lot better.

[pilvikki]

how are you feeling, kiddo?

[brandtrn]

A bit better today, thanks. The fever is down, but I've still got a killer headache, the body aches, and it feels as though somebody is sitting on my freaking chest. But, thank goodness, the sore throat is gone, so it's not killing me to drink fluids today ;-)

[pilvikki]

this ought to fix it:

[Icey]

Oh blimey ......

[yogi]

This story sounds like the times when I try to get tech support, either via e-mail or phone calls. The "support" person typically speaks English, but with an accent that is difficult for my ears to understand. What is more, they obviously don't understand my complaint, or choose to ignore it, because the assumption is that anyone who calls for support is a total idiot. The CSR's will typically be reading from a script that is flow-charted. There is no way to get them to vary from the prescribed troubleshooting dialog regardless of how much information they are given ahead of time. They are the gods of tech support after all.

I can understand how and why I must go through the above routine, but to think this same kind of thing happens within a medical staff where people are responsible for my life is nothing less than frightening. I guess it's been true all along but I've never put much thought into it. There is no way a doctor will allow his/her judgement to be challenged regardless of evidence to the contrary. Doctors do not make mistakes - it's a law. This kind of thing is actually making me welcome the day when computers with artificial intelligence will be replacing doctors. As much as I know about the flaws in technology, I'd probably have a better chance with a smart robot than an arrogant doctor. I'm thinking Web MD is that bad after all.

[Icey]

But the difference is, that AI doesn't have empathy or sympathy. Its calculations could also be wrong, because it has to be programmed to look at various possible diagnosis and prognosis, where a face-to-face chat can reveal other things going on as well.

Not all doctors're arrogant. I think the leaning towards thinking themselves as little gods is slowly disappearing, as patients have more of a say and input into their treatment these days. I've literally proved my own doctor - and a consultant wrong - but had I been diagnosed by a machine, it, too, might well've agreed with their conclusions. I followed what my body was telling me, and it turns out that they were completely wrong about something. If I'd taken the medication they offered, it could well've caused worse problems, but I felt so sure that I was doing the right thing by refusing to agree with what they were saying, that when I was proved right, both medics apologised unreservedly, and praised my common sense in researching into the matter deeply.

I don't know about over in the US, but here in the UK, we ARE allowed to challenge what doctors tell us. A recent example, is when a couple were told that their seriously ill child was going to die. Against advice and the odds, the couple took their child abroad for proton beam treatment. Today, the child's making a remarkable recovery, and no further cancer's been detected. If they'd listened to the specialists, their little one probably wouldn't be here by now, but doctors aren't infallible. They make the best decisions they can, for the individuals they see. Some get better treatments than others, but at least we have the chance of discussing these options with the professionals, instead of just blindly nodding "Yes, doctor".

[yogi]

Big Data is the scourge of the Internet because it takes a lot of computer cookies and personal data to be effective. But, the accuracy of the analysis of huge collections of data for purposes other than advertising far exceeds that which any "expert" with years of experience could muster. Assuming the collected data is from a broad enough sample, and further assuming all the symptoms can be input, there is very little chance of error in a diagnosis from an intelligent machine. Admittedly nothing can replace the compassion and face to face engagement with your health care provider, but those same well meaning professionals are biased and do not have all the information a Big Data Bank would have. Humans make errors, but data doesn't. Interpretation of the data is often the result of a well known and established mathematical analysis called linear regression. It's a method of predicting the outcome of a situation based on probability. Like it or not, cold hard analysis of data is more reliable than sympathetic professionals who just want you to feel better. Plus, I don't know of any Artificial Intelligence software that has an ego problem - well, not yet.

[brandtrn]

Update on said patient whose condition bothered me so much during that nightmare of a night...the Doc WAS wrong and I was right (no surprise there, considering the fact that we nurses spend far more time with our patients than ANY of these Docs do!). Apparently, while I was incapable of convincing the Doc to give me what I wanted, I made her uneasy enough to want to come in and see the patient herself, and she finally came to the same conclusion that I did. Guess what drug ended up being given? Atropine, which, according to the ACLS algorithm, IS the drug of choice for symptomatic bradycardia! AND soon thereafter, she was sent out for pacemaker placement (since that's NOT a procedure which is done in our hospital!). Happily, the lady did well thereafter. They could have saved that poor woman a whole lot of trouble and risk to her life (and ME a nightmare night) by addressing the issue when the woman FIRST went into sustained symptomatic bradycardia with no explanation -- but hey, I'm just a nurse, so WTF do I know???

[brandtrn]

And you are right, Dennis, about arrogant Docs. There are many who completely go ballistic if a nurse questions an order. One of the most frequent lines I've heard from some of these a**holes is "and WHAT medical school did YOU graduate from, Missy?" Ummmm...one does not *need* to be a med school graduate to put 2+2 together and to realize that the current treatment plan for a patient isn't going as it should be. We nurses ARE supposed to be the eyes and ears of the doctors, but you'd be amazed at how frequently we get blown off by the Docs when we report something we're seeing -- and then, how frequently we get blamed by them for what goes wrong when they DON'T deign to listen to what we're telling them! There ARE some awesome Docs in existence, and I've met many of them...Docs who actually LISTEN to their nurses and who respect our observations and advice and, when we question an order that's been given, patiently explain the whys and the wherefores of said order and tell us exactly what they want us to watch for after said order is carried out. Unfortunately, these Docs are outnumbered significantly by the demigods who go postal whenever an order they give is questioned :-(

[Icey]

That's a shame, but I DO think that trends're changing for the better.

Once upon a time, student nurses - and doctors - didn't dare to question what their mentors said, and by all accounts, this was particularly true for our trainee surgeons for some reason.

However, latest reports say that nurses and trainees are now actively encouraged to question procedures that they find baffling or incorrect, and this's being done for a reason. Tests actually include deliberate mistakes, to make sure that the learners're being observant, that new and better ideas might be discussed and implemented and that skilled staff can correct anything which might've been inadvertently missed.

[pilvikki]

I have enough arrogance to challenge any doctor about stuff I actually know. one of them completely ignored my complaints about horrendous muscle aches, foggy brain, sleepiness etc. totally. I brought it up again and again, was told to lose weight and exercise.

yeah, ok, but what about....?

I got onto the net and discovered that had I kept on taking crestor, i'd probably end up dead. so I stopped without telling him and i'm still around.

he's not.

[brandtrn]

Crestor (and many of the other statin drugs) are guilty of many surgical complications, in my opinion (WHAT surgery DOESN'T cause *some* kind of muscle injury, and if one is taking a med whose most common side effect is muscle pain and damage, what then?), and I don't understand why these surgeons don't tell their patients to STOP taking their statin drugs prior to surgery. We just had a knee surgery patient go into rhabdomyolysis following knee surgery, and I'm convinced that the Lipitor she was on (another statin drug) contributed to her problem. Rhabdomyolysis occurs when striated muscle (i.e., skeletal muscle) breaks down rapidly, releasing myoglobin into the bloodstream, and can lead to kidney failure if not caught and treated. The disruption in electrolytes caused by rhabdo can lead to abnormal heart rhythms and all kinds of other problems. Don't get me wrong...these drugs can help tremendously with cholesterol levels, reducing risk of heart problems, etc., but patients need to be FULLY educated re: the potential adverse effects of such medications, and I think that this is a service which is seriously lacking in most physicians' offices. Pharmacies here, I know, give printed instructions re: all medications issued, but how many people actually READ such instructions? That's WHY it's so important that the physician (or his nurse, MA, PA or whoever he/she has working with him/her) EDUCATE his/her patients on the adverse effects of any new meds prescribed BEFORE the patient leaves the office!

[Icey]

Agreed!

I also think that patients should be given information about other treatment/drugs, because it usually exists. Then the patient has a choice without blindly following what they're told.