Good Enough

Don't you hate it when you walk on the floor and hear someone being obnoxious only to find out it is going to be your patient for the next 12.5 hours? Being that for the last 8 years, I have been either a traveler, or a floater, I can just about count on it being my patient. That being said, I thought I would type about one that sticks out in my mind that I took care of several years ago.

The unit I worked on was notorious for giving me the worst patients. By "worst" I mean they could have one or more of the following: hypervigilant family members--the kind that go looking for you in the halls instead of using the call light-even intruding in to another patient's room to track you down. Or someone with multiple "needs" as in wanting you to come in the room so they can either boss you around doing things they can do for themselves--the kind who thinks the hospital is the Hilton, or all of a sudden can't use their hands or legs even though they are there for something like pre-op. (they are there the night before a surgery and nothing is really wrong with them yet--for example elective mammoplasty). Or the one who is going through DTs and no family in sight. Or someone who is demanding or degrading to the staff. Or......well really I could go on and on with the examples, but let me get to my little story.

I walked on to the unit to put my lunch in the fridge and I hear someone yelling and moaning. "Call 911! Oh Lord Jesus, won't somebody help me? OOOOOOOOHH HOOO " (dramatic fake sounding crying). I look down the hall both ways and see no one seems concerned which tells me this is not and unusual sound coming from this room.

"Please don't let that one be mine, please don't let that one be mine" I say in my head to myself.

I peek in the room as I pass when it is silent. He is lying on his side, perfectly quiet until he sees my reflection in the mirror. Then suddenly boo-hoos more along with a loud curdling scream. I go to the front desk to face my assignment, and you got it, he is mine. Plus 2 empty beds when everyone else only has one except for one staff member who has no empty beds. Not sure how that is fair, but I had been there long enough to know fairness does not extend to non staff members such as myself.

I take a deep breath and pray for the patience of a saint and decide to not make early assumptions even through the report I got from the day nurse, worn haggard from this one patient. He was in for an eye infection, abdominal pain-which they had figured out he had peritonitis and was being treated accordingly. He and had been on peritoneal dialysis for 10 years.

I entered Drama's room with a genuine smile on my face to introduce myself. He doesn't even look at me. Instead I get "You've got to get me something for this pain! You're trying to kill me I just know it!"

I find out his stomach is hurting, he has had a substantial bowel movement today and also had a platter of pain medicines. I do a quick assessment and say it is not time for pain medicines, but I am on my way to call the doctor. I also encourage slow deep breaths and to try to calm down and I would let him know what the doctor says as soon as I hear anything as I pat his large back.

"What? Calm down? Bitch I AM calm -don't you tell me I'm not hurting-you're trying to kill me to-OH LORD JESUS!" (screaming).

I quietly and as kindly as I can muster say, "I never said you weren't hurting. Did you hear me say I was going to call the doctor? Just hang in there, OK?"

"SOMEBODY CALL THE AMBULANCE, I GOT TO .....GET.....OUT .......OF HEEEERREEE!"

So then I wonder about the mental status. In report I did not get there was a history of anything, only that the day nurse tried to get his service to order a psych consult, which they did not do. So I ask the patient if he knows where he is.

"Of course I know where I am. I'm in hell and I'm hurting. Go on out of here and get me some damn pain medicine!"

"OK I am going to call the doctor now" I say and leave the room. I figure now is not the time to address the cussing, which I hate to be cussed at by patients. I call the on call MD and he says he will come see the patient. I go to the room and tell Drama the MD is on the way. More screaming. I ask if I can do anything for him in the mean time. He looks at me like I am crazy and squeals, "NOOOOO!"

So I go to the other patients and try to get them fixed and tucked in early as I know my hands are going to be full with Drama. Twenty minutes later I see orders for a stool softener and simethicone for Drama even though I told the MD about the bowel movement he had earlier. I take them to the room along with the night meds-which include a sleeping pill 2 hours early. Drama is sitting on the side of the bed. I name the medicines I have brought and notice he is grunting like he is bearing down for a bowel movement. I ask what he is doing and he yells at me to "fetch the toilet" as he continues to grunt, holding his breath. I hurry to the side of the bed and scoot the bedside commode one more inch to his leg as it is already in a place he can easily get to. (he can walk just fine) He is yelling at me to hurry after the commode is inched closer and then yells "oh no, it's too late! I boo-booed on myself and it is all your fault."

I see that his face has returned to its normal color instead of red and realise he just sat up in bed and took a dump in it. I press the call light for the CNA as I already have 3 pages for nursing needs and ask Drama is he'd like to take his meds now, or wait until the CNA can clean him up. He tells me "No, YOU are going to clean me up right now" I tell him that I am not, that I have 3 other patients who have been waiting on me and the CNA then walks in to the room, rolling her eyes behind his back, She is well versed in his antics. He then tells me the doctor never came and I am a liar.

I leave the room and call the MD back. I told him the patient said he never came to the room and I wasn't sure whether to believe him or not. The MD is just around the corner on the same floor and is astounded. "I just walked out of there 10 minutes ago....I'll be right there and I want you to come in the room with me"

So we have a mini-intervention--me, the CNA, the charge RN and the MD. Drama was confronted with his antics and lies and tried like hell to twist words around and argue. When he realised he was fighting a losing battle, he threw himself into the bed, face down and continued to yell, "Call 911! I need up out of here!"

I had the AMA papers ready and was disappointed when the MD wasn't keen to my idea. So that is how my night went in between the other patients and the 2 admissions, I had to deal with Drama's bullshit. I tried all kinds of approaches, but nothing was accomplished other than him absolutely getting under my skin and putting me in a foul mood. I searched his chart and the tests that had been run. Everything was negative so far other than nthe peritonitis and plans were in place to have him out of there soon. I refused to be his nurse the next night, and then was off for the next week.

When I returned I found out he had been transferred to the unit and DIED! "What in the world happened?" I asked.

It turns out, he was not getting over his peritonitis. They decided there was something else to it after the psych evaluation and somehow he went for an exploratory lap. They found he had perfed his small intestines and also found carcinoid tumors. They left his large abdomen open and sent him back to the unit. He went septic, had to go on hemodialysis, developed a raunchy case of calciphylaxis on top of everything and died 4 days later.

I must say I was in disbelief. And for some odd reason, my heart seemed to drop way down into my stomach. Could I have done something different? Not in the sense of figuring out what was physically wrong, but couldn't I have been more empathetic? I questioned myself out loud to the CNA who worked with me that night I had him. She very sweetly placed her hand on my shoulder and said there was no way we could have known something this bad was going to happen
to him. "You handled him better than most up here. We were all sick of him."

Somehow that did not make me feel any better.

Maybe he knew somehow and he was scared and acted out because he didn't know what else to do. The MDs were saying he was fine, they couldn't find anything that wrong with him. They, and the tests were never pointing to what ultimately happened.

I guess sometimes it is difficult to differentiate between someone being mean, acting out, and someone who somehow knows something is very bad wrong with them and must feel helpless. I promised myself to do better next time, no matter how difficult the circumstances. But at the time, I did the best I could, which maybe wasn't good enough.