Too many Chiefs in the Teepee: When Docs Battle

[NsgChica]

Too many Chiefs in the Teepee: When docs disagree about medical treatment for a patient and utimatley "forget" the patient. Ok, I am a new nurse in the ICU. We have a patient who is very old, nearing 90 with numerous co-morbidities (CRI, HTN, CAD, CHF...the list goes on), who presented to the ED with extreme abd. pain. Based on test and symptoms pt was emergently taken bake to the OR r/t pertonitis...pt eventually had an illeostomy and mucus fistula done. While in the hospital...shock of surgery (blah, blah, blah) pt. develops acute renal failure (on top of CRI).-Cr 4.6. Pt. was started on CVVH, d/t not being a good canidate for hemo because of hypotensive BP, plus it was imperative that fluid be removed over a slower, longer period of time. On top of this pt was on a lot of pressors. So pt is in bad shape. Well, 4 wks pass and pt. tries hemo w/fluid removal for the first time, couldn't tolerate it, bp drops to 70's. By the way pt. was +18 (joking) edema with massive weeping. So hemo stopped, CVVH started again. Oh yeah, her bowel perforated and caused a huge mess.

Now we have 3 disciplines following the pt. GI (for surgery), trauma intensivists (admitting doc), and Renal. These guys butt heads like crazy. One doc suggests one thing, I do it and another chews me out because I took orders from another doc...it goes on...It seems to me that everyone wants to be the hero, however, I think the most heroic thing would be to let the pt. die with dignity. I tried to talk to the family about the reality of the pt's condition, but then the surgeon comes in and paints this pretty picture about the chance of their loved one surviving. I mean there is no consensus anywhere. It's sooo fustrating. Now the family thinks the pt. is going to make it...Truth be told...pt won't make it if they can't tolerate hemo, I mean you can't go home with CVVH. We are doing all this stuff to maintain pts bp but this is only a quick fix...its only a matter of time (Mutiple organ failure). I know this is long but how do you guys deal with docs that argue amongst each other and aren't always truthful with family members???:uhoh21:

[NurseCurtis]

This is an ethical dilemma, and THE reason I left CVICU back in '05.

In the state where I worked, it was common knowledge amongst the Nurses that during low census, one (or two) of our cardiac surgeons would do CABGs on patients who were otherwise poor surgical candidates. (Failed PFT's, over 90 y/o, many co-morbidities, etc..)

Not so common knowledge, if the surgeons can keep a pt alive for at least 30 days post-op, it doesnt count against them. (AMA or some other boards)

So we're getting fresh hearts who come out needing pressors just to maintain a BP, can't wean from the vent, end up on CVVH, diprivan gtts, feeding tubes, etc...never regain consciosness--you know the drill.

SO we, the nurses--in the name of continuity of care--- are with the pt's family all day long for a month---all the while the Doc's are reasurring the family that things are promising. But come day 31, almost w/o fail, The Doc's take the families aside, and sadly inform them there;s nothing more to be done.

Hospice comes in. Orders gtts, CVVH, vent d/c'd, as the family breaks down. Me, as the nurse they've come to trust, is finally able to agree with the Doc. Sadlly, after the vent's removed, one of my final tasks is to administer enough MS04 to make them comfortable (actually causing resp. depression) while trying to reassure the surviving widow of 50 years that she is doing the best thing. When in all actuality, this should have happened the first week.

Emotionally, it almost made me quit nursing altogether, Instead, I went into the OR. :redbeathe

[imanedrn]

This is an ethical dilemma, and THE reason I left CVICU back in '05.

In the state where I worked, it was common knowledge amongst the Nurses that during low census, one (or two) of our cardiac surgeons would do CABGs on patients who were otherwise poor surgical candidates. (Failed PFT's, over 90 y/o, many co-morbidities, etc..)

Not so common knowledge, if the surgeons can keep a pt alive for at least 30 days post-op, it doesnt count against them. (AMA or some other boards)

So we're getting fresh hearts who come out needing pressors just to maintain a BP, can't wean from the vent, end up on CVVH, diprivan gtts, feeding tubes, etc...never regain consciosness--you know the drill.

SO we, the nurses--in the name of continuity of care--- are with the pt's family all day long for a month---all the while the Doc's are reasurring the family that things are promising. But come day 31, almost w/o fail, The Doc's take the families aside, and sadly inform them there;s nothing more to be done.

Hospice comes in. Orders gtts, CVVH, vent d/c'd, as the family breaks down. Me, as the nurse they've come to trust, is finally able to agree with the Doc. Sadlly, after the vent's removed, one of my final tasks is to administer enough MS04 to make them comfortable (actually causing resp. depression) while trying to reassure the surviving widow of 50 years that she is doing the best thing. When in all actuality, this should have happened the first week.

Emotionally, it almost made me quit nursing altogether, Instead, I went into the OR. :redbeathe

Wow. I would have jumped too!

[sasha1224]

On the other end.... I had a 40 something male who had lung disease. My introduction to this individual was BP in the toilet. 50s/20s. Maxed on Dopamine. Pt on head. Fluid boluses wide open. Call doc. "Well, he is terminal, there is not much we can do for him." "What else do you want? this family is not making him a DNR." Doc, "start some Neo". Ok. start Neo. Some improvement, but then backslide. Call again. "There's not much we can do, he is terminal." "Family wants everything done. Would you like the onsite doc to eval?" I hear a sigh of relief(passing the buck). "Yeah, have them come up." Call house doc and tell of eval, they come up and look. Immediately order STAT labs and add Levo. Hgb comes back in the 4s. Orders trauma blood from the bank and order transfer to acute care. Asks to have attending call to find a bed. Call back first doc. He starts to argue. i hand phone to oncall doc and I can hear them arguing. Per the attending, it took 3 acute hospitals to find a bed. Pt was transferred. F/U? Pt had bled into a PICC site attempt. Attending service had blown off the first report that the patients left arm was very swollen. the side a PICC was attempted. another group of nurses saving the MDs ass. and an example of if the onsite wasn't willing to step on the toes of the attending, another dead patient.