A students perspective...

Hello,

I am almost finished with an ADN program... I just wanted to share a bit about what happened over the past several weeks. I learned alot about the differences among various nurses and doctors and became more cynical about certain aspects of care.

Nine months ago, a dear friend asked if she could name me as her power of attorney for healthcare. I agreed. She was in remission with AML, 52 y.o. and with a family who she was afraid would be unwilling to "let go" if they faced a decision to cease care. Easy enough, it seemed.

Two weeks ago today, I received a call from her daughter stating that Mom was on her way to the hospital via the ambulance. She had been ill with bronchitis and a "cold" for about one week. They discovered her barely breathing and barely able to open her eyes. I called the E.R. and asked them to contact the staff on the ambulance to tell them she takes morphine and to consider Narcan to rule out overdose. The charge nurse sweetly assured me she would do so. The transport time was going to be approximately 50 minutes. I then headed for the hospital.

I arrived to the E.R. and spoke with the Medic who transported her. I had worked with him before, while I was an EMT. He told me he had intubated her enroute. I mentioned the morphine and he looked at me in shock... no one had called him about that. Of course he would have given Narcan.

As it turns out, Narcan would not have helped. When I found her in the E.R. she was "circling the drain". BP of 38/16, temp down to 99 (after days of spiked temps), pulse 130 and thready. As far as we knew, her leukemia was in remission so, when faced with suspected bacterial pneumonia, treatment was started. Turned out sepsis had set in.

The E.R. staff were simply outstanding. Hours later, we were able to get her to the ICU. Again, fantastic care! Though the first ICU nurse made some insulting remarks about the IV line in the scalp... I smiled when I later heard her report about her inability to get a better line for hours!

By the 5th day the infection was beaten, and we began preps to wean her off the vent. It took more than 24 hours for the Versed to wear off enough for her to wake and become reasonably responsive. Thankfully, I was able to ask her if she wanted the tube back if she was unable to breath without it... she very clearly shook her head "no".

She was extubated at about 10 am, kept breathing and by 3pm was moved to a general med/surg floor. I had left, prior to the move, to return to work. When I called at 3:45 to check in, the poor nurse admitted that she didn't even know if there was an IV running. I left work and went to the hospital. I slept there.

The day nurse was sweet and kind but was severely overloaded... I think she had 9-10 pts. My friend was so weak she could not remove the mucous she coughed up. Lack of coordination and weakness kept her from being able to raise her hand, much less push the call button. Her family members were there but were pretty immobilized by the situation. She couldn't suck through a straw so I would dribble liquid into her mouth by holding some in a straw with my finger over the top. She showed me she could swallow so we went against the orders of the doc to wait 14 hours till the next day when she could get a "swallow evaluation" by a therapist. By 5 am she was able to suck through a straw, soothing her throat.

My friend had asthma and owned a nebulizer. Using it gave her more than just physical relief... it was a psychological "control" factor, which helped her relax... The doc had ordered one breathing treatment every 6 hours. She asked for one ever 4 or so... Imagine my frustration when I would request one and be told that doctor's orders did not allow more frequent treatment. Or the amazing disappearing RT who later said he saw she was whispering to a family member so assumed she would not want a breathing tmt right then... only returning when a 2nd call was put in.

The night nurses were great... and seemed to have more time because of so many pts sleeping. By midnight the breathing tmts did slightly more than nothing to relieve my friends breathing difficulty... she was "gurgling".... CHF worsening. I called the on-call and explained the situation and he ordered 40 of Lasix. Within 45 minutes she was breathing much more easily. But the nurses were too nervous about her lower BP... which Diane and I both told them were WNL for her. Nope... no more Lasix. Then later, 20 mg.... once again doing nothing helpful.... but her BP was up... especially when she was clenching the siderails, panting for breath.

At 1:30 am she finally fell asleep... I settled into a two chairs (!) to try to nap. At 3 am the lights were switched on and a lab gal came in saying "Rise and shine, I need some blood". Aarrgghh!!!! I asked her to join me in the hall and demanded an explanation. Turned out ALL pts. have blood drawn at 3 am so the docs can have the results by 6:30 if they happen to want them that early. I told her about my friends exhaustion and need for sleep and was told that she had to have the blood drawn. I went to the charge and he explained that the only other option was for him to document that I refused to allow it. "Fine with me..." I answered. He smiled and said he respected that We had already talked about her situation and that she only wanted comfort care. Of course, the lights and discussion while the blood was drawn from the other pt. in the room woke my friend. I explained to her and suggested we go ahead with the draw since she was awake.... she asked "How bad is my blood?" and I explained the dire details... platelets really low, white count 30 k and rising... so blood was drawn. No more sleep for us.

By 6 am, neither of us had slept, as she needed almost constant help with clearing mucous and incontinence care. I can't say enough about the wonderful compassion and caring I witnessed in her night nurses! Prompt, professional care provided with a kind smile.

At 8 am I called the doc.. he had not seen her yet but her white count was up to 88 k... her leukemia was back. I mentioned hospice... he answered that he thought more days of the iv antibiotics might help. I explained that the cultures were showing the infection licked... he said he would check on that. He then spent approximately 2 minutes in her room and then told her that if she would stay in until Monday (4 more days) and stay on the IV antibiotics he might "be able to buy her a week or so more but if she goes home tomorrow she will likely be dead in a day or so".

Hospice nurse came in.. Wow!!!!!!!!!!!!! I talked to her and explained my concern about the CHF and the reality of her time left. Within 15 minutes she had reviewed the situation and returned to me with a frown. I started to say something about not wanting the doc to feel we didn't trust him.. she leaned to me and whispered in my ear "F(*&^ the doctor... she is not being told of the reality" - thankfully a daughter overheard and laughed at the audacity! The hospice nurse began prep for my friends possible homecoming the next day...

I stayed that night as well, because my friend asked me to, and she never slept. I caught a nap but she was even more wiped out by 6 am. It had taken almost an hour to get an RT in for a Breathing tmt... and then he was rude... she didn't want suctioning. The day before she had rested in feces for an hour and half though the family had asked for help twice... she was obese so they were uncertain how to help her themselves. I met that nurse and she always acted annoyed when we tried to talk to her - no way around it.. she was a royal B(*&^^^! I heard her visiting about her upcoming vacation, new shoes she had bought and more... and heaven forbid I ask about when her last meds were given! Yech!

As I left that morning I cried and told her that I was afraid that if she stayed until Monday she might not have any quality time at home wth her family and that I didn't think the doctor was being realistic about the potential benefits of more IV antibiotics... as she had already been on them for 9 days.... and could continue oral ones at home if she wanted. I asked her to think about it and give us her answer when the doc would come in later. Thankfully I had been able to have a frank discussion with her night nurses who stated that my friend couldn't get the care she needed here... that only hospice could provide it. They were worried that she wouldn't make it through the weekend with no sleep and with her resp. status deteriorating so much.

Friday am the hospice nurse got hold of the doc... he came in singing a different tune and my friend was home by 1:30 pm - reclining on a low air loss bed and surrounded by the comforts of home. The sublingual morphine and ativan helped her to relax and the 40 of Lasix she kept getting meant she only wanted her nebulizer once or twice per day. She slept and had wonderful visits with her family... enjoying the halloween costumes of her grandchildren, playing cards with her son and eating "real" food. I saw her Monday and could see she was declining.. but still able to have a wonderful visit. Tues.... slept alot... passed away Wed. evening. The family called the Hospice nurse and she stayed on the phone, coaching them to give her the morphine and ativan since Mom was in distress as her breathing was shutting down. She went to sleep. She had told us all that she did not want to die in a hospital and we were able to help her accomplish that goal.

Thanks for listening...

Kristi