Sunday, April 6, 2008

The Real ER

(Cheesy title, I know. Forgive me. P.S. I'm going to put in some links here in case anyone wants more information, and also to give a better idea of what I'm talking about.)

Last week I spent the morning in the cardiac catheterization lab, and watched a cardioversion and cardiac catheterization. We had to wear lead outfits (which weighed about 20 pounds I would guess?) and got to look inside a man's body, starting in his femoral artery and vein and snaking up to his heart. The craziest part was that he was awake the whole time! And let me tell you, when you see blood squirting a foot upward out of someone's artery on TV, it might not be that unrealistic - it really happens! I wouldn't want to work in that place though; they said that some people are so fragile when they go in for the procedure that they just die on the little table because their hearts can't handle the stress. Everyone we saw came out well though, thankfully.

After lunch, I spent 4 hours in the trauma section of the ER. The ER has one area for colds, sniffles, asthma, and other non-emergency basic care - most of the people who use it are those without insurance. The other part of the ER is divided into a trauma side and then other emergencies - those having heart attacks, reaction to chemo, or just plain... dying. I was following a nurse who had several different kinds of patients. I will just talk about one woman who made an impact on my day. Sadly, this was not necessarily a positive, happy impact.

I was led into one of the rooms, and briefly introduced to my nurse. Immediately I was hit with probably the most awful smell I've ever experienced, and I'm not exaggerating. On the small stretcher in the center of the room was an elderly African-American woman. The nurse assessed her, and her Glasgow Coma Scale rating was 4, which means that she didn't open her eyes to even painful stimuli, she made no physical motor movements, and she made only incomprehensible sounds when she was moved. This indicated she was in a deep coma. Her body was in decorticate posturing, which indicates some type of brain damage, tumor, brain hemorrhage, or stroke (above link is a picture; decorticate is the bottom image.) The picture doesn't show this, but when in decorticate posture, the arms and legs are also extremely rigid and tight to the body, so she was nearly impossible to move to start an IV, catheter, or clean her. The nurse believed that she was septic, because her blood pressure was about 60/40 (normal is 120/80) she had a fever, and obviously was in a coma of some sort.

I asked the nurse where she had come from, expecting her to say "the streets." Instead, I was surprised to find she had come from a nursing home. She said this was a common occurrence - many nursing homes take awful care of their residents, such as only changing their diapers once or twice a day, not cleaning them at all, and basically providing little to no care while charging the family several thousand dollars a month. Two patient care techs (PCTs) came in to help the nurse wash the patient, change her diaper, and start a urinary catheter. When they lifted her gown and removed the diaper, we discovered was the horrible smell was. A diaper full of feces and urine, most likely not having been changed for 8 or so hours, as it had soaked through the diaper itself, 2 very absorbent hospital bed pads, and the sheet. The real base of the odor was worse, however. What we were smelling was essentially rotting, raw human skin and muscle. She had bed sores all down her bottom, on her thighs, and on her knees from never being repositioned or cleaned properly. It was sad, depressing, and revolting that she had been treated this way, and that there are probably hundreds (thousands?) of others being taken care of this way as well.

The family came in about a half hour later - the patient's daughter and two grandchildren. It's awful and embarrassing to say, but I immediately judged them, particularly the grandson. He was in his 20s and dressed in stereotypical "gangster" clothes, with long baggy shorts, big tshirt, and baseball hat. I thought "Why are they here? Don't they know how she's been treated? Why do they even care?" One by one, each family member walked up to the patient and petted her face and hair and spoke soothingly to her, trying to get her to respond. After a few moments, they were all quietly crying, even the grandson - even me. It was heartbreaking to watch them see their family member in this state, and I silently berated myself for ever thinking that the way they appeared outwardly had anything to do with the emotions they were feeling inside. Worst of all though was the way the nurse treated them - she completely ignored them, not saying a single word to them while they spoke to the patient and cried. Thinking back, I feel terrible for not saying something to them sooner. I can only imagine how I would feel if I went to see an extremely ill family member and the nurses and doctors ignored me - I would be outraged. Once the nurse left though, I went over to the granddaughter and spoke with her and told her some basic information about her grandmother's condition. There are rules about divulging patient information, so I couldn't tell her much, but I'd like to think I comforted her at least a little. I also spoke with the patient's daughter, who told me that her elderly father was also in the ER just down the hall, so she had even more to be worried about.

My nurse had two other patients who she also basically ignored. One was Spanish-speaking only, and the other was an African-American man. I could see the judgment in her eyes when she spoke with them, and it was sad, upsetting, and disturbing. I could go on and on about those few hours I spent in the ER, but what I really hope to remember is to NOT BE LIKE THAT NURSE. She could have easily said to the septic patient's family "I'm sorry that I can't talk with you for very long, but let me tell you a few things about your grandmother/mother." There was just no excuse for the way she acted towards her patients and their relatives. Part of me is scared that I'll become desensitized to others' pain, but I hope that experiences like this will keep me from ever forgetting that inside those sick and silent bodies, a person lives and needs emotional support, too.


Amy Kalea said...

my dear. fight it. and try hard. i am not long since nursing school and i found your post by accident searching for abnormal posturing for my job. im a forensic research nurse by day and an L&D nurse by night, and we see alot of things too but in a more specific vein. It is very easy for nurses to become so judgmental and desensitized. always remember what you see and learn from it. so many nurses around me are so desensitized even when babies are born! the main problem I have found is that nurses forget that their patients are still people..someone's mother or father etc...My personal policy is always treat your patients how you would want to be treated or how you would want your family/friends to be treated...In all aspects, interpersonally and with detail, careful care. You won't go wrong that way.

good luck to you...
from one RN to a future RN

dino said...

Hi There. I am a Nurse working in the Operating Room and just like you, I always put my patients first before anything else.

I would like to comment on your post regarding to the nurse who did not show any compassion to the family. Its because the Nurse has to attend the needs of other patient in your story. But you did the right thing by comforting the family by shedding information about the patient and you did a wonderful job.

I just want to let you know that we Nurses are not superman who can do anything to please the Family. We are people too. In my experience, ive met so many families who are just so irritating and demands alot from the nurse.

The hospital im working has a 1:10 ratio.. so 1 nurse to 10 patients. thats a lot of demand from each family if all of them are nagging.

Being a nurse changes my attitude for the past 2 years. Im still compassionate towards my patient. But sometimes I ignored them during emergency situation. Like in Triage ..once your done to one patient.. you proceed to the next.

Nway.. you'll learn from this as you gain experience as a nurse. Dont ever change because what you do, reflects your actions to the new nurses/ students.

Anonymous said...

Just wondering, wouldn't the GCS here be a 5 for this patient instead of 4? Decorticate scores a 3 for motor.

Really sad story though... Hard to believe people can be treated so poorly.

Atheist said...

Yes, you are probably right about the GCS number. If I remember correctly, I got that number from the nurse that I was with and I knew a lot less then than I do now. =) Although I still can't say I know much about emergency nursing or this kind of stuff, that's probably where I got the number from. I don't remember so many details from that day now, but the anger at the maltreatment that patient and family received is sure still there.