Worry and Frustration

Evan has ADHD. You can spend 10 minutes with him and tell. We tried everything before we go the diagnosis because I believed, and still do, that the diagnosis is completely misused. Is your kid creative and bright and maybe a little bored? Medicate him. Does he not fit into the cookie-cutter image of other kids? Medicate him. It is so frustrating as a parent.

We tried everything. We met with a private psychologist, had meetings with the teacher and the guidance counselor of his school. We were told he was just really gifted and bored. And so we relayed the info to the proper people, and still received the same treatment. Pressure to put him on medication.

And then it got worse. And we took him to our family doctor, who could tell within a few minutes that he did have ADHD. We left that day with a script for ritalin. And it did nothing. Change it to Adderall and it worked. But it worked too well. You can look at the pictures of Evan over the years and tell the exact point where he started the medicine because it is like someone dimmed the light in his face, the spark in his eyes. It breaks my heart. He wouldn't eat, either. And at 8 years old, he lost so much that he dropped 25% of his weight in 3 months. And the Adderall was stopped immediately. We tried not medicating him and that lasted for about 2 weeks before we were back in the doctor's office, begging them to find something, anything to help him. The answer was Straterra, which lasted all of 2 days. Enter Concerta, and the kiddo was doin g better in class, but started to have more problems: manipulative, conniving, angry. After a couple of months of this, we said "enough" and didn't refill the prescription. That lasted about a month.

2 weeks ago, the principal of his school called us in the middle of the day and told us to not bother bringing Evan back to school unless he was medicated. I understood that he was having issues, but some of it was a stretch. For example, he got a behavior notice sent home because he accidentally farted in class. I swear. I know it's gross and we teach him manners, but he is a young boy. And when I asked him about it, he said he had a belly ache that day and he accidentally farted when he bent over to pick up a dropped pencil. And he said "excuse me". And he got a behavior notice.

I was angry at being forced to medicate him. Which, if we get down to brass tacks, was really what was happening. But what do I do? So I made an appointment for him and John took him. We asked them to put him back on Adderall because that is the only thing that got him to behave in school. I figured we could avoid the nasty side effects by just adjusting his dose. That was this past Friday. He started the medicine and--Wham!--the side effects started. The last time it at least took a few days for this to start happening. He acts like a Zombie. He won't eat. He behaves alright. Because he is too depressed and tired to misbehave. Well for the past 3 nights, he has not been sleeping at all. And complaining of a headache. And either vomiting or dry-heaving. I just had to page our family doctor and they called in a prescription for Phenergan so the poor kid can at least try to sleep without vomiting. It's horrible.
Tomorrow we take him to the doctor. And they are going to do something about this or he is stopping the medicine. I will home-school the child if I have to, though I believe doing so deprives kids of the normal social experiences of childhood. But a mom's gotta do what a mom's gotta do.

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.

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.