Today when I went to work the first thing I find out is that a patient who had necrotizing fascitis, leaving a hole in the top of his hand, who was grafted yesterday is supposed to go home today. I am the wound nurse and as I stood there with my mouth hanging open I decided to call the plastic surgeon to make sure that is what we are actually going to do.
You need to know that when this man was admitted to us 14 days ago the disease had eaten nearly the whole top of his hand. I could easily visualize bone and tendons. I put a wound vac on the very next day. With the wound vac new granulating tissue grew quickly, with the wound bed looking good and the empty spaces between the bones and tendons filled in so there was on .5 cm depth left. For some strange reason the primary who is only a general practioner made a decision this man was ready to go home, before he was even grafted. Yesterday the plastics doc comes in and while we are at the bedside says the patient is going home, with a slight question in his voice. This is a surgeon I have been working closely with, have developed a wonderful working relationship with. His attitude made me freeze and I literally didn't say a word back, just looked at him. I'm thinking, your the surgeon that is your decision. He asked me again, I quietly replied, I didn't think that was the plan, I understood the plan to be a graft, then the usual course of treatment. I was then told a graft would be scheduled, but that the patient would go right home with a mini-vac. Then he asked me why the patient had not had ROM on that hand. How do you tell the doc that he had written for no movement of the hand, (this is the normal order when we have tendons showing and are trying to grow new tissue around them), and that he had not written anything different, nor would I have sought a different order as this is what is commonly done. So he orders an intrinsic plus splint, and ROM while writing orders for surgery the following day and a mini wound vac. An intrinsic splint is not commonly used after graft because the angle is too much for a new graft. A simple half splint by ortho techs are the norm to hold the area in place and not allow the grafting process to be disturbed. Nor would you do ROM with a new graft.
Once in the hall I explain that we have to have 72 hours to obtain a mini vac for home. He tells me to push it and get it in 24 hours. I explain I can push all I want this is medicare guidelines with the policy of the wound vac company, nothing we can do. Tells me to try anyway. He is short with me, something in the nine months of working together he has never done. Tells me that the primary doc wants this man home. I want to shake him and inform him he is the surgeon, not the primary. Instead I tell him it is common practice for the surgeon to make that decision. He ignores me.
Pt. was grafted yesterday afternoon. This morning I come into an order that reads, DC patient in AM. This man still has a fresh donor site that is leaking all over the place. Order for patient to see doc on Thursday. The doc has 3 offices in 3 different towns as well as working out of the wound clinic in the host hospital. There is no specific place the patient is to go to. Which means we may or may not be able to get a Thursday appointment. The patient is very apprehensive about going home, wife is scared to death. No home care set up since this order back after 7p when patient came back after surgery. So I call the doc, tenatively raising the issue of this man going home so soon after surgery. Told that he is not the primary, but only a consulting doc. I tell him that the primary had written an order for discharge when ok for Dr.----, I am told there is nothing he can do. I question whether it is a good idea to wait a week for the dressing to be opened on this graft, normally we would open it on Monday. Tells me this is HIS decision as a DOCTOR. I say I understand but that we are doing this so different than any other I am confused and need clarification as clarification as to what we are doing. Since the patient didn't come back on a wound vac I ask if he still wants that. Answer no, couldn't get it fast enough. What about the splint? He gets all pissy because "the person who had measured for it didn't know what he was doing, an incompetant was touching my patient, he wasted 15 minutes of my life" I attempt to explain what happened, and why but he wouldn't even discuss it, telling me he didn't have time. I know it is important he understand the issue on this, but he again cuts me off. I ask about ROM, and get of course he can't have that! He still insists patient to go home. At this point I tell him the patient needs to have home care and I don't know if that can be arranged in a matter of a couple hours. I get silence. Then he goes on to ask about another patient, in a totally different tone like his normal personality, which is usually very pleasant. I get off the phone wondering what the hell is up. I went to the case manager terribly upset about sending this man home, very concerned as to how the graft will take etc... he still has a penrose drain and multiple staples on both sides of his forearm from surgery to drain the infection and attempt to save the ability for him to move his hand.
The upshot was that the CM and I decide to call the primary, let him know this man cannot safely go home without home care, and that we will likely not be able to make those arrangements in a matter of hours on a Friday. Primary calls back, I start to explain this, he starts pushing hard about getting this patient out anyway, so I give the phone to the Case Manager. She explains wife is very unhappy with this, patient wants to go but it is not a good idea because of risk of reinfection, infection of donor site etc... he says get the home care as soon as possible and get this guy out the door.
The patient is still in the hospital, will be until Monday or Tuesday when home care can take this over. The primary comes in later in the day, talks to the patient and the patients wife, comes to the nursing station and nicely tells me, I understand home care is needed, make the arrangements, I know that he will be here through the weekend, Dr. ---- is on call for me. OK. I'm standing there again dumbfounded because now it seems that he has flipped the other direction, and I don't even get why this whole thing went the way it did anyway.
I expect to catch shit for this in the end, but I protected my patient in the only way I knew how. I enjoy being a nurse, I know I am good at my job, but I am so damn tired of having to go through a labriath in order to take care of my patient, having to put up with the politics between docs, the angry and nasty attitudes when I question why we are doing something that doesn't make sense, putting up with the patient that thinks they are in the Holiday Inn etc... that I came home wondering why I keep doing this and once again scheming how to get out into another job that will pay what I make after 11 years.
I am sad and angry both. And they wonder why there is a nursing shortage.
