You are currently browsing the daily archive for August 23rd, 2008.
It wasn’t an emergency. One of my patients had been accepted into an impatient hospice center. There was still enough time in the shift for me to prepare him to go so that the next nurse may only have to wait for his ride. The last few consults still seeing him had all agreed that he should go to hospice, but all progress notes included the words “stable at this time” and “considering hospice.” So I had no actual orders. I paged the three consults still rounding and the MD on call for his attending. All the consults gave me the orders I needed. Just the attending to go. I called the answering service again to find that that MD on call had changed. Ok, let’s page that person.
An hour later I paged again. Nothing. 45 minutes later I paged again. The answering service told me she had a new pager, and maybe it wasn’t working. They would keep trying and checking back with me to see if she called. Still nothing. This was getting ridiculous. I called the hospice center to let them know what the hold-up was and to make sure there wasn’t a deadline for when they could accept him that day. No time limit. They could accept him anytime. I told my charge nurse what was happening, and she paged the house supervisor. What if a patient had been coding?
While they worked on it, I went on with the rest of my work. When I got back to the station, I was told that apparently this doctor was not answering any pages since another MD was going to be taking over that evening. They had gone ahead and paged him. He called back soon and gave me the discharge orders as I was giving report to the next nurse.
He stared blankly ahead and never made eye contact except to sneak quick glances at me while I was talking. He was a poor historian. Any answer to any question would inevitably begin with “Twenty-five years ago I was in a pedestrian accident. A car hit me going at 50 miles per hour. I was a pedestrian.” He was from a neighboring state and couldn’t explain why he was here with us, only saying “I rode a Greyhound bus. It was a nice, clean bus. I need to get to the bottom of this. I’m from ****. I don’t know the zip code. I’m in ****, now. I don’t know the zip code.” He was wearing the hospital gown over his jeans and t-shirt.
Psych was not a favorite class of mine, but I tried to remember everything I had been taught about his psychosis. He wasn’t exhibiting any paranoia, just the flat affect and disorganized speech. His room door opened away from him, so I would call out to him and identify myself before I was even in his sight. Just in case. Despite his condition, I had an easy morning with him. His blood pressure was very high, so he had regular IV meds to lower it. Cardiology rounded and scheduled a heart cath for the next morning.
Nearing the end of my shift, he complained of his IV site hurting. I looked at his wrist, and I could see a small irritated area forming around the site. I explained to him that we didn’t want to keep using an IV that is hurting him, so I would need to start a new IV. He verbalized his understanding. I came back with the supplies, and once again explained to him what I needed to do. He held his arm out stiffly to me and turned away. I continued to talk out loud and narrate what I was doing. I had his arm prepped and ready to go when I opened the needle packaging. He took one look at that needle before pulling his arm to his chest, yelling “I know what you’re doing. You and your blood samples and needles. This isn’t right.” His other fist was clenched, and I had backed away during this rant.
Therapeutic communication was another silly class I didn’t care for, but right then I wished I had a memorized dialogue. Instead, I stood quietly and as non-threateningly as possible. I was very direct with him. “Mr. Schizo, are you going to hit me?” No. “Then please open your fist.” He did. I turned and sat down in a chair across from his bed and began to talk calmly to him. We had worked together all day long. He could trust me. It was important that he have another IV for his medications and for the procedure tomorrow. Did he understand why he needed an IV? No answer. Did he need a few minutes to himself? A almost imperceptible nod. Ok, I was going to leave now. We’ll try again later.
When I came back, his arms were thrown over his face. He would not look at me or talk to me. Not even a nod or shake of his head. Right. I came back again 10 minutes later to let him know that I was leaving now. He would have a new nurse for the night. Did he need anything before I go? He shook his head no. Ok.
The night nurse was a big, burly man. When I came back the next morning, Mr. Schizo had a beautiful new IV.
