Short story: Had a new patient come home Thursday. Bed bound, wound vac, PICC line, hadn’t had a BM in 6 days. Daughter is the main caregiver and overwhelmed. Admission night I spent 2+ hours troubleshooting wound vac and attempting to replace dressing to get it to seal as dressing placed earlier in the day by hospital staff was already leaking when I got there at 6pm. Also changed PICC drsg and caps due to line being so hard to flush that it feels like I’m flushing through a clamped line. It does, however, flush and work.
Try to call MD Friday before noon when office closed twice, no return call. Try to call afterhours MD twice, no return call. I do know, however, that MD on call got my messages because along with informing about difficulties with wound vac seal, plans to do wet to dry until Monday, as I had gone through all the wound vac supplies that were sent home with patient, confirming with wound vac service that order for additional supplies had been made but Apria not able to tell me ETA of delivery, I also asked for Nystatin powder for groin fold yeast infection. Well when I got to the home for follow up visit daughter was getting call from pharmacy about nystatin powder.
Friday visit leak had reoccurred to wound vac. I attempted to troubleshoot and replace, started to leak again 10min after placement. Took it off and reviewed wet to dry with daughter. She is not taking to it well. Was there from 3-5:20pm and still didn’t get to teach SASH again to daughter because I had to teach wet to dry. Plus PICC still hard to flush and daughter had difficulty flushing.
Medicare/Medicaid patient thus ataplace needs to be set up through outpatient infusion center can’t go to ER to do it....and to be honest in the 6 years I did ER at the 4 different facilities I worked at, the only place that was willing to see the patient in the ER for ataplace was a tiny 20 bed hospital with a 3 bed ER that used their ER as an infusion center as well. All of the larger facilities wouldn’t do it as an ER visit. Problem with setting this up with an outpatient infusion center over the weekend is the patient/daughter use a state funded transportation system that requires 3 day notice for transportation. So while the line isn’t flushing great the 24hour pump for Zosyn is working.
So the second day I see this patient I get that I need additional supplies to make the wound vac work appropriately, supplies are orders but probably won’t make it there until Monday. I will need to set up outpatient infusion appointment and transportation but next week is Thanksgiving so who knows how that is going to mess with that! Also kinda getting the feeling patient needs placement and that daughter isn’t going to be able to handle all this for long. I will try to do all this Monday but at 5:20pm on a Friday I can’t do anything about it. The line is working well enough for infusion to go in, The daughter is still wanting to try to take care of patient at home, so I don’t see a reason to send her to the ER.
I have the patient added to the schedule for the weekend staff to see her at 3pm each day. Write orders for wet to dry to be preformed at each visit, please reinforce wet to dry education with daughter. Flush both lines to PICC and heparin lock red line. Then change zosyn bag and restart pump. If you have time review SASH with daughter. Also sent email to all social workers (but they don’t work weekends) that patient likely going to need placement to SNF due to daughter overwhelmed with care needs. Discussed this plan with my manager and sent out an even more descriptive email to all weekend staff with the same information I provided here. Please call with questions and gave them my personal cell phone number.
I’ll be damned if these ***es weren’t calling me going: “Well it sounds like she should have never been discharged from the hospital.” I’m like “No ***, but she was and here we are and no I don’t see a reason to send her to the ER.” “Well I have wound vac supplies but you were there over 2 hours Thursday and Friday...” And again I’m like, “That’s why I wrote for wet to dry dressings over the weekend, so you wouldn’t be there screwing with a wound vac for 2 hours like I was and I will attempt to deal with it again on Monday.” “Well she would be sent to the ER for ataplace, I mean if the PICC is that hard to flush can you even trust the medication is going in at the rate it should?!” Again I’m like “Hard to flush is not unable to use. Yes I did check and the continuous infusion over 24 hours with an elastomeric ball is working appropriately. You will still have some in the ball when you get there because on Thursday I saw her at 6pm for a 7pm dose. And yesterday I got there at 3pm and started it at 4pm. So if you go see her today at 3pm and change it there will be a little bit left, but I’ve been trying to move the dosing back so that no one is going out at 6pm to see her.” “Well, so you are wasting drug?!”
Am I working with a bunch of idiots or what?!?!?! Like I tried really hard to make it as easy as possible for them to get through the weekend as possible. WOW!?!?!?! Yes, she is a mess, yes she needs to be in a SNF, but she was discharged home with home care. I really feel what that means is that we have to now deal with this mess until it can get straighted out. Of course I would send her to the ER if I thought she wasn’t getting her medications or it looked like the daughter was not going to be able to care for her at all, but it is more like the daughter may be able to do it if she just calms down and pays attention. Right now she is overwhelmed and afraid....ultimately I think she will choose to have her mother take to SNF, but the patient is AxOx3 and currently the daughter is trying not to let her mom down. None of that requires ER admission...stupid effing co workers. I don’t know why I even spent the time writing it all down and making the orders.