Posted on by jparadisirn

Collusion (Niki coaches a parent on talking to doctors)

Chapter 13

The next night I returned to the PICU, and found that the eleven year-old transferred to the regular pediatric unit on schedule. As predicted, Dr. Eubanks not only discontinued the Fentanyl infusion before the transfer, but the puny IV morphine pushes too. It was out of my hands now. Or so I thought.

Later in the evening, I see the eleven year old’s Dad standing at the nurses’ desk, asking for me. I go to talk with him.

“What did you do last night to get my daughter pain medicine?” He demands.

“Um, I asked the PICU doctor for it,” I said. I didn’t think I should say that this was because I knew the surgeon wouldn’t order it.

“How’s she doing tonight?”

“She had a pretty good day. In the afternoon she rode a wheelchair to the play therapy room, played some games, and then walked back to her room. Right now though, she’s screaming in pain, and her mom and I can’t get her to stop. I asked the nurse to give her pain medicine, and she told me Tylenol is the only thing ordered. We gave it to her, but it doesn’t stop the pain. How do I get her more pain medicine?”

“Oh, boy,” I think to myself. My role of patient advocate is clear; I’m trying to think of how to word my answer without getting fired.

The child’s father, advocating for his daughter, doesn’t allow me this luxury.

“Are you a mother?” he asks.

“Yes I am. I have a daughter about the same age as yours,” I admit.

“So, if this were your daughter, what would you, as a nurse, do to get your daughter more pain medication?”

Silently, I think to myself, “Well, I was looking for work when I found this job…”

Out loud, I tell him the truth:

“Dr. Eubanks is a very good surgeon, but he doesn’t like his patients over sedated, so he doesn’t order a lot of pain medications for them. Your nurse isn’t calling him for more, because he will probably yell at her if she does. She’s afraid of him.”

“It’s only 9 pm. What I would do is tell the nurse I want to speak to Dr. Eubanks, now. She’ll make the call at the desk for you. When you get Dr. Eubanks on the phone, tell him your daughter is screaming in pain, and this is unacceptable; you expect her to be comfortable in the hospital. Tell him you want him to order appropriate pain medication for your daughter.”

“Got it!”  He said triumphantly. “Thank you.  Anything else?”

“Yeah, if you would not tell anyone that I coached you on this, I’d appreciate it. I’ll probably get written up if the pediatric nurses or Dr. Eubanks find out,” I solicited.

“Not a problem. I appreciate you honesty and help,” he promised, leaving the PICU, presumably looking for his daughter’s nurse.

Posted on by jparadisirn

A Happy Shift (Niki explains PICU pain management)

Chapter 12

My next shift, I take report on a child admitted following surgery earlier that afternoon. The medical plan is for her to spend the night, and then transfer to the regular pediatric unit in the morning.

The surgery was successful, and the patient will make a complete recovery.

“I’m concerned that the surgeon hasn’t ordered enough pain medication for her,” the day shift nurse says.

I look over the prescribed medications. I agree.

“How’s her pain control been for you?” I ask.

“So far, she’s mostly slept since coming back from the OR, but when the residual anesthesia wears off, she’ll hurt bad. You may have a rough night.”

“Did you call the surgeon for more meds?” I glance at her chart for the surgeon’s name, which answers my question. Of course she didn’t call. It was a waste of time.

The child’s surgeon, Dr. Eubanks is skilled and well loved by his patients and their families. Among nurses, however, he is notorious for under-medicating for pain. A nurse requesting more on behalf of her patient gets an angry refusal for her trouble.

Before judging Dr. Eubanks as a sadistic bastard, however, let me explain how some nurses contribute in the development of this behavior in some surgeons.

Bear with me.

There are three kinds of nurses whose patients always code:

The first is the most skilled and experienced nurse. She or he has Rock Star status in their unit and is the go-to nurse for the most critically ill admissions. This nurse’s patients code frequently, because they nurse the sickest of the sick.

The second nurse is the up and comer. Not yet a Rock Star, she or he is on their way to joining the rank. This nurse possesses strong skills, but is still gaining experience. They’re trusted with patients unstable enough to go badly.

The third type of nurse doesn’t really have cardiac code patients. They have patients with respiratory arrest caused by a heavy hand with narcotic administration. Often these nurses work in habitually understaffed units. For others, a sedated patient makes a happy shift. Although causing respiratory arrest is not the intent of either nurse, it’s a side effect of their care. If these nurses’ patients are intubated, respiratory arrest doesn’t occur, but they are too drowsy to wean off the ventilator in a timely manner, causing extended ICU stays.

This drives surgeons crazy. They want to avoid pneumonia, and other hospital acquired infections for their patients. They want them out of bed, moving around, and discharged home as soon as possible.

When a surgeon accumulates enough bad experiences with the third kind of nurse, distrust ensues. This distrust leads to a habit of withholding orders, and under medicating for pain. In a twisted way, this surgeon believes he or she is protecting their patients by withholding narcotics.

Clearly, further pain management education for such a nurse and surgeon combination is needed. Meanwhile, the rest of us suffer.

***

Early in the evening, my patient begins complaining of pain. I give her acetaminophen along with the spit in the bucket dose of IV morphine ordered. She quiets down a bit, but an hour later her whimpers turn to howls, and her parents demand I treat her pain. I agree.

I call Dr. Polk, who’s in the call room, and he comes in to assess the patient. Then we go to the nurse’s desk to talk.

“I’m going to start a Fentanyl drip for the night, so she can get some sleep Niki, but you know Eubanks will discontinue it the moment he rounds in the morning. If the kid spends another night in PICU, I won’t be able to repeat this.”

“I know. I won’t over sedate her, I promise. Thanks Dr. Polk.”

I start the IV infusion, and shortly, the child is comfortable. She watches a DVD with her parents before falling asleep. Dad goes home for the night. Her mom says, “Thank you,” before settling into the window seat bed in the room. I turn the lights low, and pull the room’s curtain so they can rest.

It’s a happy shift.