gtts and gits

I'm strangely compelled to write about work lately, and I don't exactly know why, except that I am beginning to believe that my latest dream about watching someone commit suicide is a metaphor for something in my own life... if I could just figure out what...

Here's a brilliant bit of conversation I may or may not have had at some point in my nursing career. Scenario: Patient is status-post angioplasty/stent X2 with a nasty looking ooze from the cath site, loaded up with Heparin and started on an Integrilin drip before coming up to the floor. Pt vasovegaled post-procedure and started oozing, requiring a manual pressure hold in the cath lab. We're attending covered on this particular unit, so I paged the attending first, not realizing how silly and futile it would be. Well, I kind of did, but I also pretty much didn't have a choice in the matter.

JAMIE:
[paging attending]
Hello. I see Pt X's orders for his Integrilin drip are standard, that is, at 1 mcg/kg or 12 gtts an hour, but apparently according to report he's actually got renal dosing at 6gtts an hour...

ATTENDING:
[cutting off conversation; huffily]
Hold on, hold on. I don't understand what you're saying. What are you talking about? [Extra snottily]: What's a gtt?

JAMIE:
[internal monologue]
Gtt: from the Latin, gutta, guttae, f., noun: drop. Also standard medical abbreviation for milliliter, or cubic centimeter.

JAMIE:
[to attending, aloud:]
Uh... milliliter, cubic centimeter? Anyhoo, the drip is going at 6 cc's an hour; it's a renal clearance dose. I need the order changed for a renal clearance dose, can you pop that order in for me, please?

ATTENDING:
[indistinct muttering]

JAMIE:
Oh, and the patient is having severe back pain similar to what he had last procedue; says he sustained an old back injury. I see he's only got Tylenol ordered; can we give him something stronger?

ATTENDING:
[huffy again]

No! Absolutely not.! He's got Tylenol ordered, that's what he can have. I'm not ordering anything else. [as if it wasn't perfectly clear the first time] He can just have the Tylenol!

[hangs up phone]

Down but not out, I paged his APRN, who was more than happy to put in the correct order for the Integrilin drip (because you know, it's nice to have correct orders written, and the attending certainly wasn't about to do squat) and eventually got something ordered for pain.

About a half hour later, the patient starts having nausea, vomitting and severe, unremitting radiating pain to his testicles. Due to the fact that he's still slowly oozing from his groin site despite manual pressure and a sandbag and he's on an Integrilin drip, I start to worry, thinking maybe, just maybe, this guy is bleeding into his belly. I get back on the phone with the attending, who is apparently not at all pleased to have to talk to a stupid nurse about potential life-threatening complications of the procedure, because what the fuck would a dumbass nurse know about extraperitoneal pelvic bleeds? I explain the situation, fully and perhaps naiively expecting something rational, like an ultrasound, or an abdominal CT scan, or maybe both, plus a stat CBC, to be ordered.

Oh, wishful thinking.

ATTENDING:
Oh, you know what? Just put a foley in him. He had this problem last procedure. Couldn't void. Put a foley in him.

JAMIE:
[Stunned, but continuing to belabor situation while having simultaneous visions of nursing license spontenously combusting]

Uh? A foley? Just a foley? Are you sure? You don't want a...

ATTENDING:
[confidently, cutting off conversation]

Yes. A foley.

So, back to the drawing board (not to mentioning paging the APRN) it was. Of course, when I explained the same thing to his APRN, the immediate response was, "I think this guy really needs a stat U/S; he could be bleeding into his belly. I'll be up to see him as soon as I can."

Thank you, Jesus. And thank you for creating caring mid-level professionals who don't mind being rational and actually coming up to see a patient in distress.

The funny thing was, both the attending and the APRN came up at the same time, and the attending was all, "We don't need any of that other stuff, just a foley." Oh, really.

Needless to say, I didn't send away transport, and he went down fo the U/S and CAT scan after the foley went in. And lo, the patient did have a bleed in his belly. And lo, the attending, who basically didn't want to be paged all night, shipped him off to an ICU for poor interns and residents to deal with all night.

Ergo, I had to explain to this patient (because apparently the doctor couldn't be bothered to reassure his own patient in person) in some of the most delicate verbal tapdancing I've done in awhile with some fancy crap along the lines of : Don't worry, it'll all be okay, we're just sending you to the ICU so uh, you can be covered by housestaff, because uh, your doctor uh, thinks it would be, uh... safer (yeah, that's it! Safer! That's a good, reassuring word!) if you had in-house coverage overnight, blah blah blah.

PATIENT:
Wow. The ICU, huh? Wow.
[Translation: Oh my god! Something is obviously very, very wrong with me, and you're not fucking going to own up to it, are you?]

JAMIE:
[fibbing, just a little bit, seeing the worry on the patient's face, in what she hopes is her best reassuring tone]

Well, the patients on the subacute side are generally the same level that we take here in our unit; the difference is that you'll have in-house staff covering you all night long. Your doctor feels it will be safer for you.
[Translation: Your doctor doesn't want to be paged in the middle of the night, at all, ever, for any reason, and by the way, he thought a friggin' foley was all you needed, so the fact that you're getting a first year doctor as your primary tonight is probably a massive improvement on the situation.]

PATIENT:
[vaguely]

Oh, okay. The ICU, huh?

Dude, that like, totally sucked. And one of the things that bothered me is how damn nice this guy and his family was; all "Thank you for telling me what's going on." and "I'm so sorry I'm in so much pain; I really hate to bother you." And here I was, trying my best to be helpful and reassuring, and not getting it particularly right on either account. I just hope the guy is okay, in the end, because he deserves it.