Patient-isms and the Almighty ED

I am a compassionate person, for the most part. I swear it. If you are my patient, you can bank on the fact that I will do my best to take care of you. Without judgment, without fail. If you, in your lack of medical knowledge, say something that is utterly stupid in the strongest sense of the word, you can rest assured that I am not going to laugh at you in your face.

I’ll wait until I leave the room.

Recently heard by my patients:

“ I need my BEEEEPAP!”

“All I know is that when she was a baby, they had to put her in a plastic bag.” From a mom when asked for the history of her young infant’s delivery. My response? “ You mean they had to BAG her. As in a way for us to give manual breaths. I assure you that they did not put her in a plastic bag.”

“He said I have an internal fart. Something is blocking it from coming out.” Upon hearing that they have a myocardial infarction caused by a blockage of one of the coronary arteries.

“You have to SHUT UP! I have anxiety and the voices in my head said you’re being too loud!” This wouldn’t be funny if the patient were really mentally ill and wasn’t just trying to get some benzos for the weekend.

Of course these are just a few. And they all occured in the ER. This doesn’t include the funny crap we see. Like the stripper who fell off of her pole. Or the arrests. And the drunken people. My job is always, always interesting.

Case in point: just a few short minutes ago, I held in my hot little hands a real-life FBI badge. You know, like the one they flash on tv. Turns out they are just as badass as they seem.

First Do No Harm

Primum non nocere.

Of course we all recognize this as the cardinal rule of any medical practice. Nonmaleficence, meaning that it is entirely possible that the best course of action for me to take in an emergency is to actually do nothing. That doing nothing, and thus not causing further harm, may be better than being wrong in a manner that leaves my patient in worse shape. Now take all of that and combine it and roll it into a big ball and realize that I grapple with this in a split second when my patient has stopped breathing. That instant that truly seems like an eternity. The great void between the realization that your  patient is indeed pulseless and apneic, and the pushing of the big blue button that will trigger the calling of a Code Blue. In my career, I have had situations where I go back and think about  a patient and wonder if me reaching any conclusions sooner would have changed an outcome. And thus far, I have had the luxury of being able to say that I don’t feel as if I have harmed anyone.

Last night, I had to face that possibility when, after some aggressive airway management for a patient who wasn’t ventilating well, I witnessed the spiral. First the oxygen saturation starts to drop. And then the blood pressure is low, followed by the slowing of the heart rate. Finally you reach that chasm where the heart ceases to beat, whether it be a pulseless ventricular rhythm or completely asystolic. The patient is dead. Expired. And you can do all you can and whip out everything you have learned in years of education and professional experience in the hopes that it will help. That the heart will resume beating. (Not so much the breathing because, honey, I can make anyone breathe with the right equipment.) But this happened last night. While I was there with my hands on that patient, taking the opportunity to teach a new ICU nurse about ventilator basics. I have never had that happen to me. And after we got her back not once, but twice, and they finally got the stat chest film for which I kept begging, it was determined my patient had a pneumothorax. And so when the family arrived at the bedside and told us to stop all efforts at resuscitation due to patient wishes, in the blink of an eye, my role switched from caring for the patient to caring for the family. To help them find some peace in her death. I did all I knew to do. I extubated her, washed her face, smoothed her hair, tucked her in, and left the room so they could have those final moments with her on her death bed.

And then I went into my back office in the ICU and I cried. Actually I started crying before I got there, prompting fellow ICU staff to follow me to make sure I was okay. I was. I was still breathing. My patient wasn’t. It was the first time in my career where I was physically working with a patient when they went down, and my instantaneous thought was, “Did I do that? Did I hurt her?” Of course after logically recounting the steps to her demise, it is obvious to me that she suffered the pneumothorax before I did anything that could have caused it, and thus I cannot blame myself. But it just did something to me, and I cannot really explain why.

I love my job. Love it. But I have always had confidence in my professional skills and training. I haven’t really doubted myself before this. Well, I have, but not in the manner that I had to stop and think on whether or not I did damage. I have always said that the most dangerous person in healthcare is the one who will not admit that they don’t know everything. So with that in mind, there has always been a healthy dose of fear. There has to be when you are literally running someone’s life support. But that fear cannot be so great that in inhibits one’s performance, one’s ability to be on their toes when a true life-and-death emergency strikes.

Lately, as a senior therapist, I have been mainly working the critical care units. Once in a blue moon, my boss will give me something else so I don’t go insane, but it isn’t very often. And the thing about this is that I am in a teaching hospital. Meaning when there is an emergency and the code team assembles, it really is a team effort. In other areas of the hospital, this may not necessarily be the case because there are more seasoned physicians running the show. But in the ICU’s, you get residents. And the presence of “MD” behind their names has yet to give them the idea that they know all because of their education level. They know that an experienced ICU nurse or therapist has seen a lot and can help them. I work with them on intubations, on managing pulmonary issues. I give crash courses in blood gas interpretation or ventilator management. And in a code, when we get to the point where we have exhausted all possible causes, or in one where the cause is obviously pulmonary in nature, they look to the therapist. Me.

I don’t know what I’m getting at here. I think it is just that I had to think last night that it was possible that I hurt a patient. And even after coming to the conclusion that I did not, the fact that I could have just seemed to linger. And of course this has made me think of my role in the hospital even more than I have before. The pressure. The weight. The responsibility.

I upheld my ethical commitment last night. I did no harm. But I had to come face to face with the idea that I hold lives in my hands when I go to work and clock in at night. That I very well could hurt someone. I think it just caught up with me.

Going Back

My name is Andrea, and I'm a student.

Again.

Barring any complications, I head back to class on April 3rd to begin the completion of my business degree. Since everything else is good to go, all I have to do to get a Bachelors o Science in Business Admin. with an emphasis on healthcare administration is to take the actual business courses. My stuff from my other degree exempts me from the rest.

It sounds so strange. Me. A business major.

Life does funny things to us sometimes. I never saw myself doing anything other than medicine. Never wanting to do anything else. Strange how having Zachy changed me that much. But not one for stagnation, I want to ensure that I have the needed degrees to take my current career as far as I want. Years from now, I don't want to be limited because I didn't take the time to get the degrees while I had the chance.

I'm doing a program that will have it all finished within 18 months so I can hurry up and move onto my MBA in healthcare management. I'm nervous and excited. I usually perform very well academically, and you cannot convince me that these courses will be any more of a challenge, or even as much of a challenge, as graduate-level human genetics, where I actually extracted and mapped DNA, or senior-level o.chem, which just about killed me, I swear. And I did all of thesre while working 70 hours per week, while being Mom Extraordinare, John's keeper, and keeping straight A's. Can you tell I'm trying to give myself a pep talk?

Because I have officially been out of school for a year. And now I have 2 kids, one of which is a baby who wants to wreak havoc on my laptop each and everytime I open it up.

I can do this, right?

I'm both excited and nervous. The less I am doing, the more bored and stressed I get. I'm the weird one for which happiness means a bursting schedule and a to-do list as long as I am tall. So on that note, I'm ready to go back. It's just that doing so means the end of this chapter: the chapter of my pregnancy, Zach's birth, and Zach's first year of life. I gave him as much of myself as I could for this past year. We both needed it. Now it time for me to do something for myself once again.

Let the juggling begin.

Big Brother (or Sister) Has It In For Fatties

A surefire way to piss off a control freak like me is to tell me what I have to do. Seriously. If you let me think it is my idea, I'll do it. But telling me??? Oh no, no, no.

And I work for a private Catholic hospital.
And they tell me all sorts of things.

For example, my birth control: Insurance pays zilch for it. Whatevs, I don't think the $43/ month self-pay expense is going to kill me. I am a little disgruntled that they would pay almost half a million dollars for Zachy's entrance into this world, yet still not consider my bc pill medically necessary, which is the only way they will pay. And there is no better way to convince the powers that be that you are bound for damnation than to tell them you are preventing pregnancy. Seriously.

So the latest and greatest: our fricken cafeteria.
Let's discuss this, shall we?
Our cafeteria is decent. And they open it for us night-shifters at 2AM every night, which is great. But at night, the food sucks. The lettuce on the salad bar is brown, the food on the hot bar congealed, the lady at the grill afraid of the actual grill and thus cooks everything at too-low temps ( nothing like getting salmonella at a hospital cafeteria!). It's bad. But on a few nights a week, we have a good cook, and she will make you anything and it will be edible, I promise. Enter the problem here.
They decided they care about our hearts. And our cholesterol. And our risk for hypertension. And so I walk into the cafeteria one night and I see the horror. No-Fry Friday. I shit you not. All I wanted was my damned chicken quesadilla, which it says on the menu is a heart-healthy choice! But nope! The grill is closed down. And on a night when the good cook is working! Oh the HORROR! The lettuce on the salad bar was brown. There was something made with mushrooms on the hot bar (highly allergic). There was no pizza-by-the-slice. And all that was in the cooler were little containers of potato salad (allergic to mustard, too). I ate a Heath bar, a blueberry muffin, and some potato chips. The quesadilla would have been better for me! For real!

So we are all disgruntled, right? And it is the talk of the hospital. We are all going to call everyone from the cashier working the register. all the way up to the President of the United States, in order to get our cheeseburgers back. A serious revolt was on the brink. And then Monday hit.

Meatless Monday.
You have got to be freaking kidding me. Seriously. No pizza. Still no grill. Still brown lettuce, but now no hot bar either. I ate popcorn and a Tootsie pop. Chased with a cup of coffee to replace the energy I would not be getting from my meal.

My hospital cares that my thighs have fat on them.
No, they don't.
They care that our insurance, though through Humana, is privately funded, and they have to pay for all of our heart attacks when the time comes.

Hey, Hospital BigWigs! I'll give you a hint: a heart attack would be much cheaper than one of my pregnancies. Just sayin'.

The Most Dangerous Person in Healthcare

I have always said that the most dangerous person in healthcare is the one who will not admit that they do not know everything. Plain and simple. We all have our dumbass moments. This goes for doctors, nurses, therapists, techs. None of us are immune. At some point in someone's career, they will encounter a new patient who is a bit more challenging or has a condition with which we have not had much experience, or will be exposed to a new type of procedure or a newly-developed better way of doing things. It is the nature of the work we do.

With that being said...

We all also have our moments of, well, cockiness. We know when we are right. The good doctor/ nurse/ therapist, when faced with these moments, will admit that they could possibly be incorrect, but they feel confident that they are correct, and they will assert themselves with the other members of the healthcare team. The beauty of this job is that there are almost always tests that can be done to confirm our hunches. One has to find that delicate balance of speaking up and advocating for the patient when they think they are correct, yet still be humble enough to know that the human body is design at its greatest and we will never understand every single miniscule thing.

And then there are new grads.

The newly degree-holding, newly licensed, newly credentialed beasts that they are. We all were new grads once. Yes, me too. But I don't ever recall a time where I had this sort of issue. I can reflect back on my time when my role switched from being a college student completing patient care under the licensure of my preceptors and instructors, to being a big girl with my own license and credentials. Yeah, I felt like a million bucks the first time I signed my name. Andrea, RRT, RCP. Those capital letters behind my last name to let people know I was qualified just seem to do something to people. For me? I was scared to death. And I made a career move that would later serve me well in my transition of roles: I took a position at a small hospital where there was only one therapist staffed at night---me. I didn't have the luxury of hanging back timidly while the more experienced took over. I was in the thick of it: full arrests coming into the ER, asthmatic kids, emphysematous grandparents, and neonates needing resuscitations. And so I got over my fear. And became confident in my skills and my education and my abilities while realizing that there is no way, in that tiny hospital, I encountered every curve ball the human body can throw our way. Stellar career move. The best thing I coud have done for myself starting from scratch, even though it wasn't intentional. Truthfully, I started out with a salary and benefits package that was pretty obscene for someone with such a lack of experience, and that is what drew me in. It was only later, when I discovered I belong in a big hospital and I am charged with more critical care that I made the realization that the first role I had made me a better therapist.

So back to other new grads...
Where in the blue Hell did they come from? And in case someone from my work comes across my blog, let me clarify that I am not speaking of one in particular, or even one discipline. It is a New Breed. Gone are the days when they bow to the more experienced like we did. And no field is exempt. Gone are the days where they emerged from college, looking scared and timid. When they valued the input of those who have been practicing for as long as they have been alive. Yes, we all sign our name with the same credentials, but in my department, we are blessed to have some pretty experienced therapists in our midst. And I will be the first to say that if any one of those ever have something to teach me, I am all ears. They have seen more than I have seen, done more than I have done. But the new grads of today? They don't have that humility, that attitude. And this goes for all: doctors, nurses, therapists, techs. I can remember when it was that time of year and the first-year residents showed up at the hospital. You could always spot them with their scared-to-death stare with eyes as wide as dinner plates. And they knew that, even with MD behind thir names, they still did not know as much as an ICU nurse or RT who had been in their field for years. They would humbly ask me to tutor them on ABG interpretation or help them intubate the tricky airway. Not anymore. A few weeks ago I had a code where the first-year tried and tried to intubate, causing trauma to the patient's airway and allowing the patient to get too hypoxic between attempts to where I finally had to yell at her to stop and let me deliver some breaths. And she looked at me, aghast, stating that she was a doctor. Yes, she was, but that was MY patient.

The sad thing is that I am exactly where you find these arrogant beasts these days--night shift. Day shift positions in hospitals are pretty coveted and snatched up by those with more seniority. The vacant positions are almost always on nights. And so I am stuck. Night shift is very, very young. And maybe it is that I have been doing this for enough years that I am starting to develop the salty crust of experience. Maybe it really is that new grad these days are arrogant SOB's. Whatever he cause, it is leaving me feeling old and weary and seasoned in a way I didn't feel before.