Tuesday, March 01, 2011

The Frustration Keeps Rolling In

I'm writing this in two parts today, just to make my life easier.  First of all, quiet night, thank you.  Busy morning.  First of all, new renal Dr. came on service today and decided not to go by the previous Dr.  Sent the dialysis person down to try to get the line old working.  Which didn't work.  Sometime this afternoon, they are putting in a new line, in an emergent situation, because his bun and creatinine levels are going too high.  His lung x-ray is worse because he's building fluid, a ton of fluid.  He's 88 lbs more of fluid than when he came in.

He's making some urine on his own.  Depending on who you talk to as to whether it's a good thing or an indifferent thing.  Some say it's good, others say, dialysis patients sometimes make urine but not enough to take off the poisons.

The dr.s sneaked around me to do rounds on him today.  So, I didn't get to listen in, his nurse missed it to, they were so sneaky about it.  This is why I feel they were being sneaky.  Normally, always, they have done rounds right in front of his room and I go out and stand in the hallway, listen and ask any questions based on what I hear.  Today, they rounded on him while they were standing at the room next door.  I didn't want to break patient privacy so I stayed in the room.  When I thought they were going to do him next, I came out to be told, they had already rounded on him.

If this is how they are going to keep the fellow Dr. Overbearing out of my radar, it's not good.  It's just pissing me off more.  Makes me feel like I'm being punished for speaking up and not tolerating bad behavior.  I requested that he not address me personally.  I realize he's part of the team and would speaking during rounds, I don't have a problem with that.  Just don't address me personally.  Send another messenger.  We'll see if this continues.  Doesn't help a new attending is coming on tomorrow, with this other drama playing out.  I hope this new fellow Dr. O, goes away soon.  I'm amused by the fact that his real last name starts with O, for overbearing.

The palliative team came down and spoke with me today.  Just as NurseNikki said, they were distressed at the conversation I had with Dr. O.  They most certainly help with comfort care in other areas than hospice and end of life stuff.  Wonderful caring ladies the NP and the Dr.  They listened to my concerns and are assessing his file and will make recommendations from there.  Which is good, because the Propofol they are using lowers his blood pressure to the point they can't do dialysis.  When they lower the drug, he becomes agitated.

I've been wondering why I'm just so exhausted all the time.  It's no wonder.  So much information to process in so many areas, renal team, pulmonary team,infectious control drs,  at one short point cardiology, and palliative care.  Then asking questions and decisions to make, input to give.  Hour by hour it's a new onslaught.  Watching the monitors.  I've gotten so I can pick up on changes to his vital signs, the different stimuli that will make it go up or down.  I feel like I'm connected to him through that tv screen.  Also, I'm a bit of an empath.  I don't tell them that, otherwise they'll really think I'm a nutcase.  It's helped with my nursing career in the past and I have an uncanny ability to communicate with people who cannot speak.

That was just my morning.  It's just a brief overview, you can only imagine what it was really like.  My ride is going to be here in an hour.  I think I'm going to knit, watch some tv and decompress.  Yet another day of saying to hell with housework.  I wish these cats would get something done around here while I'm gone.  Lazy little beasties.  I know the busy bunnies would, but they are easily distracted.  Oooo shiny.

Act 2:  I got up there just a little after four pm and his bed was missing.  Not surprised, but wondering what they did for consent as they hadn't called me.  Someone half erased a couple numbers of my cell number on the board, and for some reason they kept saying they can't reach me at home.  It's correct number on file.  Either someone doesn't know how to dial correctly, or there is something with the hospital that only they can't reach me.  So, two dr.s signed off.  This happens quite frequently and makes me wonder why I'm MPOA.

This probably won't come up.  But it also makes me wonder if they should want to do something I don't agree with, if they'll just have two dr.s sign off and over ride me.  Like I said, I don't think it will come up in this situation, it just makes me wonder.

He has a new renal catheter in the right side of his neck, his jugular vein.  Everybody on the count of two.  Grimace, ooooh, ouch, eeeew.  Yeah, it's necessary but I just can't imagine.  He still has the femoral one in waiting for the renal guy to come down and take it out.

Palliative care ordered his oxycodone and ativan to be doubled, so they could lessen his drip meds.  Namely the sedation.  This gets frustrating when you read further.  Trying to figure out how word this so it doesn't get confusing.  I guess I should start with observations made over the weekend and work forward.

As I said before, when they lighten the sedation his blood pressure goes way up. It does come down some if they give him a bolus of the pain med.  When they turn the sedation up his blood pressure goes way down as that is a side effect of the propofol.  The weekend nurse made a sideways comment of, "We can't keep controlling his blood pressure with propofol."  I didn't say anything, just stored it away.

He's had a different nurse the past two days, that won't be on tomorrow. She's a good nurse.  But I have observed, she's been watching and controlling his blood pressure with the propofol.  When his bp goes up, she turns up the sedative rather trying a bolus or turning his pain med up a bit.  When his bp gets too low she turns it back down. Last night she said to me, when she started ten years ago, they just kept everyone very sedated until the day to remove the vent and she never heard of any ICU psychosis.

When the order came to double the other meds, she just gave them to him but didn't turn the propofol down.  Thirty minutes before dialysis is to show up, his pressure is too low for them to attempt it.  He NEEDS the dialysis.  They were making good progress with the vent weaning until the renal people started fiddle farting around about getting him proper dialysis.  The vent weaning has been on hold and he is up to 80% oxygen.

She turns it down some, and we move him around in bed so his bp is up to where the dialysis people won't refuse.  They are late coming, by about an hour.  So she turns the propofol back up a bit, to lower his bp. *head desk*  I made sure to move his hands around, stroke his forward, and talk to him when they showed up so his bp would go back up.

I'm not giving up hope, but man they're killing me by inches.  It's gone past frustrating into maddening.

I need someone to volunteer to come cook for me.  Not because I don't have food, but because I'm so tired of trying to figure out what I want to eat then cook it, when I come home so late and tired.  Hell, you don't even have to come over and cook.  Just bring me a plate of whatever your having. D did most of the cooking and I was glad for whatever he handed me.  It drove him crazy that I didn't have opinion about what he made most of the time.  When he gets home and able to cook again, I'm going to be excited about everything he makes, whether I have an opinion or not.  Liver and onions.  Yum, yum.  Mashed potatoes and gravy. Yes, yummy.  (Wait, I shouldn't put that in print.  I HATE mashed potatoes. He'll suspect something then.)  Please don't send me any plates of mashed potatoes.

Not much reading for him the past couple days.  So many interruptions and things going on, that when it's quiet I just let him rest.  Some knitting has been accomplished for WIPW tomorrow's post.  It's finally up to 80F and sunny here, all week.

I'll stop rambling now.  Thank you for stopping by and sticking with me.


Rudee said...

Frankly I'm exhausted for you just reading what you've been through. If I lived closer, I'd cook you a good Arabic feast--so no mashed potatoes. Just good and tasty food.

I'm so glad you got to meet the palliative care team and hope their changes bring something positive to the table.

Here's hoping that Wednesday brings better news.

by Teresa said...

Denise, how long can you keep this up? You need to get some "bag dinners" -- Bertoli -- the best is the chicken and spinach and bowtie pasta. Just simmer it on the stove and stir occasionally til the pasta is done. We love them and they're tasty and healthy.

You'll need to take a day off too honey.

Love from OR.

nursenikkiknits said...

Rolling is right! Sounds like a real roller coaster.
Please try to eat and get enough sleep. I have a 2yr old and 6 mo old (nothing like what you are going through!) but I know the days are much tougher to take when I haven't had a good night and am skipping meals. It's like they say on the airplane - put your mask on first then try to help others. The first step in helping D is to look after yourself.
I think you are doing a great job for him. I hope soon he won't need all those meds and his body will get a chance to heal itself.

CraftyCripple said...

Talking about the line in the neck reminded me of having one put in while conscious on the ICU. It was really disgusting and made me feel sick. The nurse apologised and said most people who had this done were out cold and didn't have the whole ewwww factor to deal with.

You need to knit a cushion to strap to your forehead if you are going to keep banging the desk with it. I hope that your next visit is less vexing. Sounds like you had a horrendous day.

Maybe you could put a sign by the road - all meals gratefully received. It would be interesting to see if it works.

It sounds like virtual hugs are in order after your crappy day so ....

((((((HUGE HUGS))))))

Hang on in there.

Daniele said...

Wow, you are a trooper! Hang in there. HUGS

melbatoast68 said...

I so wish there was something I could do for you other than to fuss at you to eat, drink water and get rest. You are constantly in my thoughts. I hope today brings good news!