Categories
State of the art
Month: June 2020
I walked into work last night at 18:30 with a giant smile, hidden under my mask of course, and a pep in my step. It was night 3 if 3, but it was going to be a great night, I proclaimed! Because I had woken up to a full pot of coffee already brewed and waiting for me. Nothing a night shifter loves more in life than coffee.
I even had to brag about making all 26 assignments that morning and not having a single person complain to me or ask me to change their assignment— either before or after start of shift. It was unprecedented, and I was feeling pretty good about myself.
Fast forward only a brief 30 minutes and three people were asking to go home at 23:00 if we were overstaffed, and a hospital that had accepted a transfer patient tried to refuse once we called to tell them that the transporters were about to leave and the ETA was 45 minutes.
We solved that problem but then also kept busy for the next few hours with transferring 2 more patients out of ICU, providing end of life care for an end stage liver disease patient whose illness surpassed her body’s ability to fight back, and we accepted 3 admissions from outside hospitals and 1 admission from the emergency department. Not to mention making sure all 25 nurses on duty get breaks…
The next 8 hours didn’t get any easier. There were multiple simultaneous rapid response calls (RRTs) with one that turned into a Code Blue. We accepted and then un-accepted more transfers because we kept getting calls for more urgent cases. We had a way-too-young patient brought to us after a out-of-hospital cardiac arrest with several more in-hospital cardiac arrests (all in a short time frame) that needed ECMO placed for full heart/lung failure. Because of this, we had to refuse a Tylenol overdose in liver failure, also a life threatening condition—but not as time sensitive at that moment.
Another unexpected transfer from an outside was a patient with recent cardiac surgery who had suffered a stroke and whose brain was swelling. This patient needed emergency neurosurgery but was at a hospital without a neurosurgeon.
Luckily, by which I mean not, we had already been waking up the neurosurgeon frequently because one of his other patients with a hemorrhagic stroke was also having some pretty serious problems. Her ICP kept rising, and she was starting to have cardiac complications from the myriad medications we were using to keep her from bleeding into her brain more. Her heart was having 15 second “pauses” which honestly, is enough time to almost make everyone else have a heart attack.
While adjust her medications so that her heart stopped stopping, just 2 rooms down, a cardiology patient admitted only the night before was decompensating as well. She came in with what was presumed to be heart failure and fluid overload. But upon closer inspection also appeared to be harboring severe signs of sepsis. There was a battle going on however between what we as nurses could see going on with patient and what the cardiology team wanted to do.
Also, we had an unfortunate problem in this case. A family member who is a cardiologist, and actually a cardiologist who trained at our hospital but now works elsewhere, wanted to 100% dictate the care. And they let her. She chose the attending cardiologist, she set the treatment plan. There was to be no changes.
To make a long story with a lot of history and precedent much shorter: The patient was DNR. Her heart rate, which had been in the 120s to compensate for the infection and cardiac issues she was having, dipped to the 60s and then quickly into the 30s. At this point she had no pulse and was having a PEA arrest (pulseless electrical activity). Someone called me to the room by literally screaming to me as I valiantly tried and failed to get a cup of coffee. I got to the room as a young baby doctor with fear in her eyes stuttered indecipherable things while looking at her phone.
The nurse whom I trust implicitly looked straight at me as I entered the room and told me what I needed to know as I saw her heart rate. “She’s a DNR.” The nurse is calmly standing on one side of the bed, hand on where the patient’s radial pulse would be, if she had one. I cross to the other side, take the patient’s hand. She is cold, not breathing. The heart rate on the telemetry monitor reads 33 but the heart is not actually pumping. There is not pulse. Another nurse comes in to help and I shake my head no to her as she looks at the monitor.
The doctor is on the phone with her supervisor asking about pacing or this or that. We close her eyes. Take off the oxygen mask, turn off the IV medications and disconnect them. I look at the doctor as she gets off the phone. I shake my head. At this point, we have turned off the patients monitor. There was no longer any visible vital signs.
As the doctor leaves the room to call our patient’s family, we begin washing her. This is a most important step for us to take to give dignity and pay respect to those who pass away in the confines of the ICU.
But it is only 04:00. It will be more than 4 hours before I leave at the end of my shift. In that time, I send 2 more nurses on break. I review the charts for 25 patients. 2 admits arrive to settle in. And I give report on I-don’t-even-remember-how-many-patients-we-ultimately-ended-up-with to the day shift.
And it all started with me bragging about what a great day it was going to be because I woke up to a fresh pot of coffee already brewed for me. Also, we literally checked if it was a full moon at one point. It wasn’t— it was a new moon. So it was my fault. I’ll take the blame this time.
I’m still left to wonder though: why are nurses so superstitious???
Heath care is a strange place where I see silence occur in many forms as a type of violence against black & brown peoples, and especially important to me: women… this week, 2 things. In my career I’ve never been the silent type, but I hope sharing examples of what I classify as racism and sexism in healthcare can help expand our conversation. And if even one more person gets a voice… that is all that matters.
1. We received a patient from the emergency department. I was reviewing the EKGs since she had a funky rhythm on telemetry… and up in the corner, where you can type in demographic info—but you are not required to—I see that this patient is labeled as “Oriental.” I check the other EKG. It says “Asian.” I am floored. Why would you type this in? “Oriental” describes a rug not a person. I speak to a colleague who used to work in the ED and we contact a charge nurse there to follow up on this. Giving this person the benefit of the doubt and not reporting to risk management for now.
2. The second case is more complicated, but one I see in different variations much more often. Details are approximated from several cases. An older Asian woman, a mother of loving involved children and a wife, has been hospitalized in the ICU since April. She has “failed extubation” many times and had a breathing tube for the majority of her time with us. She has also had several cardiac arrests. She has end-stage renal disease and thus has been on continuous dialysis as well.
This is a critically ill patient who due to her multiple conditions and has one nurse assigned only to her— to run her dialysis and keep her safe. Every night at rounds someone offhandedly mentions that we should really address goals of care with the family.
Discussing goals of care (GOC) is one of the main things doctors are responsible for in the ICU. You need to assess how the patient would like to live should she survive to be discharged from the hospital. And this sounds brutal, but upon admission or during the course of an ICU stay, many suffer drastically life-altering medical events. Strokes that will leave you paralyzed on one side and fed through a tube in your stomach. A heart attack that will make you unable to do any activity but walk from your recliner to the bathroom. A kidney injury that will require you to go to dialysis three times a week for the rest of your life. A lung infection that damages your lungs so badly that you need a tracheostomy and rely on a machine to breathe for the rest of your life—thus making it nearly impossible to ever go “home” again.
So it is up to doctors, and sometimes nurses too, to have conversations with patients and their families about these things. Is this how your mom would want to live? What does she enjoy doing and will she be able to do that after her hospitalization??? The answers to these questions can inform then what treatments we provide—but more importantly, don’t provide.
So back to our older Asian mother and wife, receiving dialysis and unable to come off the breathing machine. At this point, she’s been in the hospital 1.5 months. It seems like some GOC discussions should have taken place, right??? Well this week, she received a tracheotomy. During the procedure she received sedation, which they continued for 24 hours post procedure to allow for more comfort during the initial period when she might bleed—so that she could rest, hopefully reducing the risk of said bleeding.
During the second night in which she didn’t wake up, despite being off sedation and on dialysis—which would clear the drugs, I started getting alarmed. What would happen if she never woke up? I went into the chart to review the GOC notes I so naively assumed must be there. You see, I wasn’t her bedside nurse—but instead one of the charge nurses on a busy ICU in a major city.
I could find no GOC notes. No palliative care consult. In a month and a half. Nothing. What the f*ck was going on???
An overly solicitous deference to the family of Asian women for decision making and tacit agreement to “do everything” without a conversation. In these instances, the female patient is most often left out of the discussion altogether. Even if the patient is clearly suffering or clearly doesn’t want the interventions. The nurses often become the patients only voice— forcing the doctors to talk to the family about the patient’s wishes.
This is a practice done out of respect for “traditional” values in Asian cultures, but is ultimately looks to me like racism and patriarchy when it flaunts modern medical ethics and the premise of “first do no harm.”
This patient had no desire for a tracheostomy. In fact, she hated the breathing tube. She hated the hospital. Will she retain her will to live when she is put into a long term care facility? My feeling is no. And so it was my duty to speak up. To ask why there had been no palliative care meeting. To question the ethics of what we’d done already. When I go back to work next week, I hope to find some answers in her chart.
Categories
First time for everything
Categories
Let’s talk about the carotid hold
Today in California, Governor Newsom announced that he would like to do away with the “carotid hold”—a restraint technique taught to police and a modified version of which killed George Floyd.
https://www.sfgate.com/bayarea/article/News-calls-for-end-to-carotid-hold-15320522.php
Some consider the carotid hold and a chokehold to be synonymous but police departments have differentiated by saying that a chokehold comes from the front and brings with it a possibility of cutting off the airway while a correctly done carotid hold only compresses the carotid arteries, leaving the airway intact.
So, why was the kneeling that we all saw performed by a police officer in Minnesota a type of carotid hold? Because anything designed to compress the carotid artery—which will cut off blood flow to the brain and cause unconsciousness quickly—is this type of “hold.”
And while people are already arguing whether or not this applies to the case of George Floyd, if you watch the video, it is clear that while Mr. Floyd is lying prone on the ground with his head turned to the side, former officer Chauvin is kneeling on the side of his neck directly on his carotid artery. Only occluding one (instead of both sides) would certain prolong the process of cutting off blood to the brain and causing unconsciousness, but a person could certainly still lose consciousness. And here’s the important part: once Me. Floyd loses consciousness, his neck relaxes and any attempt he was making to protect his airway is compromised. So at this point, it is likely that Chauvin had not only cut off the supply of blood to his brain causing unconsciousness but was also cutting off the air supply to his lungs as Mr. Floyd’s neck relaxed and changed position.
The bottom line is this: no oxygen getting to the lungs, no blood getting to the brain. From this point, it only takes seconds (maybe as little as 10) for a person’s heart to stop. So Mr. Floyd then experienced a cardiac arrest, as confirmed by the autopsy. His heart had stopped. The only thing that would have saved his life is CPR and immediate intervention by health care professionals. A delay of more than 3 minutes guarantees at the very least a brain injury and at the very worst the outcome we have.
Why am I so fixated on this issue, you might be thinking??? A few reasons.
- The goal of a correctly performed carotid hold is unconsciousness. Why should this ever EVER be the goal of the police?
- A correctly performed carotid hold should last for less than 30 seconds and once the “goal” of unconsciousness is met, the subject then needs to be correctly positioned in order to not sustain further injuries and he now needs medical attention.
- It is very difficult to perform a carotid hold correctly, which is why some view it synonymously with the choke hold (which purposefully cuts off your air supply by applying pressure to your trachea).
- But accidentally slipping into a choke hold, which seems like it would be very easy (especially if the subject is struggling) is not the only medical danger of of a carotid hold. Applying pressure to the carotid arteries can cause tearing of those arteries (called a carotid dissection) or it can loosen atherosclerotic plaques in the arteries which then shoot into the brain, causing one or more strokes. Let’s look a little closer at these 2 medical complications, shall we?
- Carotid dissection: this is where the artery tears from the rough pressure being applied to it. It can also happen from having your neck adjusted at the chiropractor, vigorous exercises, etcetera… you probably won’t know this has happened right away because despite the fact that we call it a dissection, it is not normal for all the layers of the artery to tear and for you to bleed spontaneously or prolifically into your neck. Usually, only one layer out of three tears, and the body’s response is to send in all your clotting products to fix the small tear. This is the problem, though! In trying to fix itself, your body creates a loose “clot” of platelets and other things which easily break off from the inside of the artery. Because the arteries carry blood to the head at a pretty substantial pressure, this clot, or embolism as we call it, will go up into the brain traveling as far as it can in the arteries until it gets stuck. Everything beyond it then is NOT receiving oxygenated blood flow. You are now having what we call an embolic ischemic stroke. Since it is being caused by a carotid dissection, you could actually have many at the same time as multiple thrombi cut off the blood flow in different arteries in your brain. This complication could start occurring days to a week after the event which caused it— and the early symptoms are quite hard to recognize sometimes..
- Like a dissection, the second complication is also an ischemic stroke at the root— but the cause of ischemia in this case is from broken off pieces of atherosclerotic plaques in the carotid arteries. This is the mechanism for how heart attacks occur as well and was the driving force behind trying to get people to call strokes “brain attacks.” I am glad that never caught on, but I understand why they tried.
- In the end, my thoughts keep returning to this: a medical professional would never screw around with someone’s carotid arteries—why should the police who are not trained to understand the permanent harm they can do.
- The closest we come to purposefully compressing the carotid arteries is a technique for lowering a dangerously high heart rate called carotid massage. Even during this procedure, our goal is not to block blood flow to the brain though—we are trying to “massage” or activate the bundle of nerves surrounding the carotid artery below the jawline which will trigger your heart rate to go down. This procedure is almost always done by a doctor, although an ICU nurse may be trained for this, and it can cause the type stroke I mentioned above. This is a procedure of last resort. And you can listen over the arteries with a stethoscope for a carotid “bruit” which would indicate turbulent blood flow and most likely significant atherosclerosis that is a direct contra-indication to carotid massage. In this case, we would not use this procedure in this patient.
https://www.stroke.org/en/about-stroke/types-of-stroke/ischemic-stroke-clots
First, do no harm. The ethical principle that guides healthcare professionals. we struggle every day to do no harm, as patients kick punch & bite us. As patients berate us verbally, as families demand care for their ill loved ones that we know will prolong their suffering but provide little chance of recovery. We do it with a smile and a gracious heart. Because we are taking care of human beings. People who suffer and make mistakes just like we do. People who celebrate life’s victories and milestones just like we do.
When will the police start doing no harm? Carotid hold & other violent restraint techniques need to end.
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Non-racist vs. anti-racist
Here’s a list of things we can DO to start being anti-racist. Actions to take. It always helps, in times of turmoil, to just DO A THING. Don’t sit around moping, feeling guilty and just wondering how to help. Use your privilege & your skills now to take action.
https://medium.com/equality-includes-you/what-white-people-can-do-for-racial-justice-f2d18b0e0234
Also, another resource of note: an article describing white privilege in quite a bit of depth, with a prologue that defines bias vs. racism, extending to the definition of white privilege and the problems of understanding this phrase in today’s economy, as well as an exploration of power. Take a peek.
https://www.tolerance.org/magazine/fall-2018/what-is-white-privilege-really
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We must all be better
I haven’t even been able to form coherent thoughts about all my emotions over the last week. So. Many. Feelings. So. Much. Destruction.
But I have always been acutely aware of white privilege and especially institutionalized racism. My 13 years in nursing have been a constant battle to teach the baby doctors that the very basis of their education is both racist and sexist and that they are going to need to be conscious every day to make sure they don’t fall into a comfortable practice of relying on that privilege to make decisions for those in their care.
Plus, I’ve lived in the cities & the metro areas. I’ve watched this police violence going on so long, I wonder how it’s possible that it can still happen— that it is not obvious to everyone that it is happening. I witness the rage of Americans targeted because of skin color. I witness the horrible assumptions people make about other people. And it breaks my heart. And some days, I am filled with rage too.
As a nurse, it is my job to treat everyone. Full stop. No matter race nor gender nor politics nor any other imaginable category. And honestly, my most basic core value is simply to accept other humans exactly as they are. Everyone has a choice to be who they want. The only time you & I will have a problem is if you tell me I can’t be something— for instance, my mother believes that I cannot be a good person because I do not believe in her religion. But that’s another story for another post…
My point is: I treat everyone equally as a nurse. Police should do the same.
Read what nurses in Minneapolis are doing & feeling right now in response to the George Floyd shooting here:
https://www.refinery29.com/en-us/2020/06/9849136/nurse-black-lives-matter-protest-response