Dear MD, please write some orders for me. Thanks, your friendly RN

(Here's somethin you don't hear out of nurse blogs on a regular basis.)

Dear MD,

I did not go to medical school, nor did I do residency. I am not a doctor. I'm a nurse. I know a lot about health and medicine, pathophys and pharmacology. I can predict with a good degree of accuracy what drugs, doses, diagnostics and treatments make sense for a patient.

An MD should WANT me to be able to do this. We have a human-made and broken health care system and mistakes happen all the time. I am another clinician that helps protect patients by ensuring the drugs and treatments you want for our patient do what we both want them to do.

But the fact is that you have twice the amount of time, and a much more comprehensive training in the field. I don't diagnose. I don't prescribe. Yay for us both and for the patient. I have a good degree of accuracy....enough that I feel confident seeing a nurse practitioner for my general health stuff. But for my more complicated breathing stuff, I see a pulmonologist. I know the difference.

Here's my trouble: when I come to dialyze our patients, I get the name of a hospital, a last name, and sometimes a room number. I don't get any report on these individuals; I do not have the luxury of reading health and physical history, recent orders or even speaking to the patient before I get 75% of my dialysis treatment set up. I get some lab values, which allow me to predict the correct potassium prescription.

Let's go back to that sentance. I get some lab values and predict a potassium prescription (granted it's not that hard for dialysate) in a population with common comorbid cardiac issues.

What I ask of you is that you write me some orders for the treatment parameters. When I receive the chart, I often am going on orders you wrote for a dialysis treatment two weeks ago. Sometimes the patient gets two hours of a treatment I decide upon before you see them that day. Sometimes it's their first treatment and I am making those decisions until you arrive an hour or two into the treatment.

The good news is that I'm right most of the time. It is first grade math to subtract a serum potassium from seven.

The bad news is that I do not have MD behind my name and you do. Please don't leave these decisions to me. Please don't grouse when I ask you to write me some orders for the treatment I'm halfway through completing. Please don't look at me as if I'm a moron who's asking to be told what to do when it's seemingly obvious what I should do.

It protects us both. It's best for the patient. I do not have any business deciding how much potassium to give a patient, how much Epogen, how fast to dialyze a new patient who's never had dialysis before. I know that. I also know you're busy and have 35 patients to see today. I get it. I also know most of the other nurses on the team do this all the time. But I think they allow this to continue because they interpret this possible laziness/busy-ness on your part to be a vote of confidence in them.

It doesn't take much to subtract from seven, yes. But what you may not know is that other physicians are altering other electrolytes through the treatment that are providing benefit to the patient. They're giving additional drugs that may be beneficial. They're even having me change the direction of my dialysate flow (something I need to know 35 minutes beFORE patient arrival), to reduce the risk of adverse outcomes on new patients.

That's not first grade stuff. And for treatments I 'prescribe', I don't do that. But maybe you should. Or maybe it goes through your head to consider, but you never get around to writing it down, so it never happens.

I respect what you know. This laziness is possibly a nod of confidence to me, or maybe you think any monkey can do what I do. Either way, I don't care. It isn't right and there are clear legal scope of practice boundaries, no matter how busy we are. These boundaries are for the best of the patient.

So just. Please, write me some orders.
Thanks
/jo

Clinical case study du jour.

So I got a call at 17:00ish today to go to the Hilton Hospital of Suburban Growth Upon My City (you know, the one with the Starbucks). All I get is: "Go to HH of SGUMC, ICU bed 42, patient's name is Fritz and he just left a week ago. His K+ is 8."

(I was gonna name the patient something like Schwarzenpfluger but I decided that's too many letters to type repeatedly. I picked 'Fritz' instead, because it's a nice name and makes me think of nice schnauzers I have known.) (Why I'd think of schnauzers I don't know. It's been a longass day.) (Note: Patient is not of German heritage...Germany is just on the brain this week.)

So my first thought is that Fritz went home and then didn't go to his dialysis appointments, and then someone found him dead, called 911 and there you have it.

Patient is early-mid40s, alert, chatty, polite. He doesn't look like an end stage renal patient at all. He doesn't even look like he was dead a few hours ago. No apparent neurological residual...he's freakin texting somebody on his cell when you get in. (Can you imagine that text: Dude! Died today. Came back. Txt me when you get this.) ....but definitely not a chronic kidney....his skin is healthy, for one. He's not depressed, for two. Third, he's not watching either Jerry Springer or the Food Network, and I'm pretty sure that having kidney disease compels you to do one of those things.

"Hi Fritz, I'm JustCallMeJo and I'm here to dialyze you."

"Nice to meet you."

*boggle* Really? Did I get the right room? I address him by name to double-check. I set up my machines; I get Fritz's story.

(Also notice that the patient is on a nasal cannula only, so of course <_5L of O2, rhythm in a grossly normal-appearing sinus tach, satting well for altitude, with a normotensive blood pressure. Other assessment findings: c/o 6/10 pain, pericardial rub, pulses all palp and regular, wheezes post left lower lobe, bowel sounds hypoactive, 1+ edema BLE, two fentanyl patches on back of scapulae, permcath to R IJ and a #18 rather ugly field IV in the L AC, unmessy #20 R hand IV.)

Turns out he has mediastinal cancer, which I would not wish upon Pol Pot. It's horrible, cruel and unusual. It metastasized to a kidney. To complicate things, his first round of high octane chemo caused acute tubular necrosis (as chemo sometimes does.) Acute kidney disease became chronic kidney disease, and he became dependent upon dialysis.

This all sucks in ways profound and deep. But this guy decides to choose life when life has handed him lemons laced with battery acid and prune juice. Amazingly, he's on board. He has GONE to his dialysis appointments as scheduled. He and his wife are asking me good questions about the renal diet, which IS genuinely confusing and difficult. One of his parents is present, and the parent asks me really detailed questions about kidney physiology and how the dialysis machine works. ("So, what are the filter fibers made of?") (What ARE the fibers made of? I have never been asked that.) (I'm explaining finer points of ultrafiltration, diffusion, osmosis and molecule size of creatinine to people who are ASKING about it. I mean, nobody but ME likes that stuff.)

Point is, this is a guy that intends to live. This is a guy that will do whatever sucky things life is requiring him to do. This is not my usual patient at ALL.

So.

This morning, his wife finds him down, unresponsive, foaming at the mouth. She does CPR. For real. Jane Anybody calls 911, does CPR ...and this woman saved her husband's life. (I just think that's amazing.) EMTs arrive, intubate him, lights and sirens to the HH of SGUMC. Upon arrival, he codes again. They find his potassium to be 7.3. During the code, they did glucose, insulin, bicarb and calcium. No Kayexalate, no Narcan, no Romazicon. Some intensivist decides to call the nephrologist in to evaluate for stat dialysis. Meanwhile, as they're getting a nephrologist to come in urgently, who then has to see the patient, call the scheduler, who calls me, who drives through rush hour traffic, yadayda....the patient stabilizes and they decide to extubate the patient.

And then, I guess, he resumes text messaging his friends. And then he has chicken soup for dinner, which he says is too salty.

*******

Aren't there things that bug you about this picture?

....

So I'm thinkin it was a VT arrest, end of story. However, parent of Fritz is at bedside and parent asks aloud, "But what about all those drugs you're on? You took extra didn't you?" Parent obviously disapproves of narcotics. I ask patient what he's on. He gives me a litany of narcotics. It is enough to kill a herd of cattle, and maybe a few small rodents, too. I assure parent that the son has mediastinal cancer, which is very painful, and I explain the pathophys of narcotic tolerance. The difference between the patient's prescribed dose and the "extra" he took was a single tab of PO Dilaudid. I don't know the patient's pain and narc history, but I do know that it's possible that the "extra dose" is a drop in the bucket, equivalent to a glass of wine for me. Could one glass of wine, after enough on board, toss me over the edge? I suppose it could.

So.

There's a question in the patient's mind as well as with the physicians and nurses of what deadified him twice today: cardiac arrest (from the high K+) or respiratory arrest (from the narcs). But again, no Narcan was done, and the twelve lead EKG shows a wildly unremarkable sinus tach. On the flipside, the patient lives with a potassium of over 5, so who knows how much it would take to send his heart into an arrhythmia.

***********

I'm still thinkin cardiac because, well, if it looks like a duck and sounds like a duck.... I might be wrong. I have RN behind my name, not MD. My job is to treat, not to diagnose. There's a whole lot I am sure I am missing, particularly since I know squat about oncology.

I asked the nephrologist of course. He doesn't know for sure, yet. ("Come on, he doesn't look at ALL like a status post respiratory failure, this guy's had a cardiac event today, don't you think...?" "Yeah, I'm with you, but there's so much goin on with this guy. It feels like that, but it could just be a combination of both.") An hour later, he called me to ask me to change some things with the treatment. He's out supposed to be having fun at a party but he's checked out, thinkin about this patient.

I think the real mystery is: Why was his potassium that high?

* I can't imagine diet alone doing it. (His PO4 also elevated.) I suppose my imagination is limited, but if the potato famine didn't wipe out all of Ireland, I'm not sure diet alone is that efficient.

* He didn't skip dialysis treatments (and his hemo treatments are being done by a source that suggests extremely unlikely that he was dialyzed with an acid bath of 16 or something ridiculous like that.)

* He last bout of chemo (which might have caused mass lysis of cells, causing a flood of potassium into his bloodstream) was three weeks ago.

* His wbcs are low, but I've seen far worse. Infection? Leading to lysis? His lactate was elevated somewhat. ?

* I can't imagine it being so no-brainer as he's accidentally taking potassium pills. This patient has had his life upside down and entrails out for less than a year...he has a polypharmacy stash of narcotics. But I doubt he's like my 70something polypharmacy patient with old stashes of cardiac and diabetic meds that might get mixed up.

* Again with the....Less than twenty four hours post full four hour hemodialysis treatment. Even if the acid bath was wrong, it would have had to be dangerously, wildly, toxic, deadly wrong to produce a serum potassium of 7.3. (Can you even supersaturate an acid solution with that much KCl?) I just don't see a mechanism for that to have happened.

So what did happen?

....


....

I have four days off, which I'm delighted about. But I kinda am really curious about what happened to this patient today.

Mostly, I'm writing this down just to dump it outta my head so I can sleep. Sheesh, it's 0155 a.m. I'm off call in 4 hours. Yay for me.

...My day started at my Home Hospital with a nosepickin, Jerry Springer-watchin, morbidly obese patient who asked me "where the beauty salon is in this hospital." She "needs a cut."

For real.

But then on hospital #3 of the day, I got to Fritz. And people like Fritz, and his family, are the reason I do this stuff.

And then there's the tiny little good things...

So I go to hook up my periotoneal dialysis patient last night, right, and his wife is present. She usually does this for him at home. I got my mask and gloves and jazz on, and he doesn't have a dressing on his access. His skin's a little red, too. (Red = infection = possibly leading to peritonitis = earthshakingly and life-changingly BAD for PD patients.)

So I say, "Where's your dressing?" The wife blurts out: "YOU ARE THE FIRST NURSE TO ASK THAT IN DAYS! THAT'S EXACTLY RIGHT! HE NEEDS THAT DRESSING ON OR HE'LL GET PERITONITIS!"

Er. Yeah. ? She gives me her own stash of gentamycin ointment and I do a dressing that takes me 5 seconds. But she's very very excited that I'm a "good nurse" who "pays attention" to "the important things." She asks for my boss's name and her phone number, as well as my last name, because she wants to call my boss to tell her what a good job I've done.

Weird.

I mean, that's nice, if she does that. It's really nice.

It's just curious to me because my brain flashes on much, much harder things I've done for people in my nursing career. (The precordial thump that actually worked comes to mind....giving narcan to the woman with stage IV breast cancer....on rehab, the other woman with stage IV breast CA who also had a MASSIVE PE...the man we put in the 360degree turning bed, his wife and the evil surgeon.) I can think of bedside surgical procedures I've assisted with, like the day I held the fully conscious SDH patient's head while the neurosurgeon used a hand drill on his skull....or "Mary", the mother of two with fulminant liver failure and the good GOD Herculean efforts by the entire ICU team.

It's a good list for a four-year-out RN, and every nurse has their own.

A five second completely nothing dressing gets a thank you call to my boss.

Huh.

That's really nice. Nice things happen where you really don't expect them, don't they?