The Death-Eaters

Hi, there, everybody! You remember me from my previous post, wherein I was a disgruntled employee of the healthcare system.

I'm still somewhat disgruntled after Thursday, but for different reasons (namely, trying to keep a nonagerian in end stage renal failure "alive" with hardcore antibiotics for a new diagnosis of "rule out sepsis" and pointless CT scans for vague and highly questionable patient complaints of tummy pain.) All this mania occured *after* she drops her temp to 94.1 overnight and we have to bring in the Bair hugger to raise her temps. Then she had hemodyalisis, so of course her temp is elevated by the time ID (Infectious Disease) folks comes to see her. At which point they examine her and get their panties all in a bunch; the rational, I'm sure, being something along the lines of: Oh my Gawd! Her temp is slightly elevated at 100.6! Bring on the cavalry! Let's break out the IV Vanco, stat! Let's draw some ABGs, stat! CXR! Abdominal CT scan!

Uh, thanks, ID intern and resident consultants, for making this particular exercise in futility possible.

Of course, this is also after I've spoken to both interns regarding the Bairhugger issue and the hemodyalsis issue (as in, "Are you sure you think she's septic? Maybe she's just having a slight hemo reaction, or uh, maybe we warmed her up a tad much in the Bairhugger. Don't you want to wait and see before we bring out the Big Guns and shut down her system even more with the whole broad-spectrum antibiotic thing?" Or at least that was the point I was trying to get across. Perhaps I should not have been so subtle. I must have given the woman intern a funny look when she said she was going to order the Vanco dose, stat, as in, "Am I hearing you correctly?" But I figured that perhaps the covering PA could talk some sense into these folks, so I kept my mouth shut.

And okay, so I realize that the temp was just part of the clinical picture, but still. How much fucking lamer could this medical plan get? I wondered. Never ask a stupid question, because it will be answered for you all too soon, and probably with results you won't care for much, too.

By the time I realized they were drawing ABGs on her recently-made-DNR/DNI-person (Why? To prove what we already know, which is that she's acidotic?) , I realized I was fighting a losing battle. I think it was at the point when they sent up the contrast-dye for her CT scan that I just about about lost it.

As in, Shit, guys, I know to you I'm just a dumbass-know-nothing nurse, but when I tell you THREE TIMES EACH the woman is ASPIRATING ON A TEASPOON OF WATER AND HAS STOPPED TAKING ANYTHING PO LITERALLY OVERNIGHT, I really really mean it. It also means you should get a goddamn clue already, and not order contrast abdominal CT scans on a woman whose mental status has vastly deterioriated overnight and of whom you claim said she had "belly pain" (a complaint neither I nor the PA who went in to do the scutwork of drawing ABGs, etc, could not elicit from the client, because basically she can no longer tell you what's hurting her, much less why.) Sigh. Ergo, phone call number one to house officer initiated.

I have often wondered these formative salad years of nursing, what the fuck everyone must be thinking when it comes to these lovely patients, who are clearly dying, and why it is some feel they must try absolutely everything on a body and spirit that is giving up the will and ability to live? Everything I was seeing clinically in my patient pointed to the fact that she is not long for the world and had suffered significant, dramatic drawbacks in the mere 16 hours between my last shift and the one following, and there was nothing on this side of heaven and hell that would have made me believe she was on some miraculous road to recovery because of one goddamn last minute ID consult.

And yet here I was, shuffling this poor lady off to CT scan in the middle of the night, wondering bitterly why it was she had everything else ordered for her but what she really needed, something to control her suffering, which was starting to manifest itself in heartwrenching, stacatto moans peculiar to the dying. To be fair, I believe part of the reason nursing perspectives can be so vastly different from the actual plan of medical care falls on the different roles we play in healthcare, and the fact that consults come in with little or no knowledge about your patient except for what's been passed on (formally or informally). They see a snapshot of the clinical picture, a moment frozen in time, and they are obliged to act on it, even if it seems silly or irrelevant from another standpoint, namely nursing, which has the advantage of knowing a patient over time.

What they don't stick around long enough to see or hear is the actual, dying patient, unless they are dying in an acute situation like a code. As nurses, we do. It is a unique privilege, but it is also a burden, because to listen and watch a dying patient tormented by the increasing inability to breathe, let along control their own bowel function, voluntary movements, speech, and tolerance to pain, is to be privy to a world of anguish I never thought possible. And sometimes we watch them die over months, although usually it takes a few days or weeks at most once they start the process of actively dying. The question then becomes for me, How do we justify prolongation of a patient's suffering in light of the inevitable? Is the justifcation valid and sufficient evidence to continue treatment? Under what moral argument and reasoning?

So, on the phone again with the house officer for what would be one in a half dozen times over my shift, I secured an order for IVP morphine and it did the trick, allowing her to rest comfortably for a few hours, but my heart ached to know that my hand, too, was implicated in protracting her suffering. It was the only measure of nursing care from a pharmalogic standpoint that I felt good about the entire night, and that, my friends, is unbearably sad. No, tragic.