Tuesday, March 08, 2016

There is a bloody bite block on my wall, just above my desk.

It's in a biohazard bag, don't worry. It's pinned to my wall, just above my desk, so that I can see it every single morning and remember why the hell I got into this crazy business in the first place.

We do a significant number of what are called transesophageal echocardiograms on our unit. Unlike transthoracic echoes, which take place when a tech holds an echo wand against your chest, a TEE takes place under moderate sedation, with a cardiologist feeding a long, skinny tube with an echo camera on the end of it down your throat.

You can't do this without sedation. Try, and you'll end up with a retching, fighting patient and a poor-quality image. It's just flat impossible to ask an alert human to stand for having a two-foot length of something the thickness of my index finger inserted down his or her throat and manipulated. So we sedate. We're a critical-care unit; we're all trained to administer sedation and recover patients who've been sedated.

Then, one day, Doctor deSade showed up. Dr. deS. was a new guy for us, from a different branch of cardiology, and nobody had worked with him before. The initial signs weren't promising: normally TEEs are done early in the morning, both because we want our patients to have time to get over their sedation and because they've not had anything to eat or drink since midnight. This dude promised to show up at around eleven, which is pushing it, but then didn't show up until past two o'clock.

Kitty and I each had a patient undergoing a TEE that day, so we gathered our sedation meds, our throat-numbing sprays, and our sedation-med-antidotes. The first patient was mine.

Dr. deSade put the bite block (a firm foam widget with a hole in the middle that keeps a person from biting on whatever's placed in her mouth) in, after spraying the patient's throat with benzocaine, and began to feed the probe down. "Do you want any sedation?" I asked.

"Give her one and twenty-five," he replied.

(Now: "one and twenty-five" refers to the milligrams of Versed and the micrograms of Fentanyl that the patient is getting. We normally sedate at two and twenty-five, going up from there in two milligram and twenty-five microgram steps. It's not unusual for a patient to soak up five of Versed and a hundred of Fentanyl. Both are short-acting and easy to reverse, so we prefer to front-load the patient, as it were, giving them more sedation at the beginning, and letting it wear off gradually toward the end of the procedure. So one and twenty-five was weird.)

She fought. She gagged. She cried. I had to hold her hands down as the procedure continued, and I got very nervous about her blood pressure--up into the 260's systolic, which is a dangerous place for a post-brain-bleed patient to be. Eventually, Dr. deS. agreed to let me give her another milligram of Versed, but no more. Absolutely no more.

So, at the end of the case, after I'd pulled the bloody bite block out of her mouth--and you really have to work to bite hard enough to draw blood with a block in--I stuck the block into my glove and then into my pocket. And I took Dr. deSade aside, where nobody could hear us.

"Listen," I said, "I understand you have a personal protocol for your TEEs, but we also have to make sure that our patients don't have to deal with a lot of discomfort. This woman's blood pressure was far, far too high for safety. You might consider administering more sedative before beginning, so as to lower the risk of complications in this patient population."

I had been formulating that speech for the entire twenty minutes of the TEE. What Dr. deSade did flipped me right the fuck out: he started shouting.

He continued shouting all the way up to the nurses' station, where he leveled a finger at me and shouted, "I want to write this nurse up for unprofessional behavior and for questioning my orders!"

And that, my chickens, was when the line I'd rehearsed every day in front of the mirror for more than a decade came unbidden to my lips: "Just make sure you spell my name right."

I think I hissed it.

Poor Kitty had to do a TEE after Dr. deS had had his tantrum, and guess what? Her patient did the same thing. Moreover, the guy had had another TEE a few months before and unfavorably compared Dr. deSade's to his previous one, within the doctor's hearing.

And I got written up.

But Dr. deSade got written up twice, independently, by both Kit and me, for being a fucking jackass when it came to sedation.

My patient cried when I told her how sorry I was. She was expressively aphasic, but could understand everything that was happening. I have never felt so bad as I did that afternoon--I wasn't able to protect her from somebody with an ego problem and an attitude.

Both the TEEs came back, read by a different cardiologist, as having poor image quality due to patient agitation. The write-up Dr. deS filed wasn't acted on; the ones Kitty and I filed were. Dr. deSade is no longer welcome anywhere near our patients.

Sometimes doing the right thing is why you get into a business as irritating and emotionally draining as nursing. And sometimes, to remind yourself of all of that, you keep a biohazard above your desk.


bobbie said...

Good for you and Kitty for sticking to your guns.

Jenny Hart Boren said...

Wow! Just…wow. Great post. Thank you.

Elle said...

My God, that's awful. Those poor patients. That rat-bastard doctor ... we can only hope that someday he has a stroke and can't practice anymore. How upsetting for you and the other nurse, too.

Steff said...

I'm still in nursing school (graduate in May!) and there have been situations during clinicals where docs were NOT doing the best they could for patients, the nurse talked with me about it after and said it happens all the time and blah blah blah but nothing was done about it. And it was stuff that would be totally against policy. I was upset that none of the nurses did anything so I am glad to know there are nurses in the world with a backbone that can stand up for what they know is right! I hope in the real world of nursing with my own patients I can do that as well.

Allison said...

Excellent post. I also enjoyed the gifs in the other post (as well as that post). I love it when you write.

RehabRN said...

OMG. So glad he's not near anymore of your people.

Sending someone to stroke land just because a nurse asked if you could give some more sedative is truly cruel and inhuman.

I have heard stories my husband Dahey tells me about when his father (an MD) almost killed a surgeon who was a similar a$5 to his mother after her surgery in a local hospital. This made me think of that, and what it must have took not to throttle him.

Wow. Good for you. He shall get his due.

Anonymous said...

Outstanding. I especially loved the part about you practicing in front of a mirror for a decade+ exactly what you would do in a situation like that. I am gratified that the administration supported you.

Jess said...

I'm a Neuro nurse too & I think you are everything that is right with nursing. Thank you for writing and reminding us why we are doing what we do.

clairesmum said...

I am so glad you and Kitty are who you are, and that your administration backed you up. There is a real risk of being fired and black-balled as a 'problem' nurse when you speak up against abusive MDs. Your patients are lucky to be in your care!

Old Fool said...

Although Head nurse and Oldfoolrn are far apart on the time - space continuum, our philosophies are similar. I am adding you to my linkage. Would you consider reciprocating? I'm at oldfoolrn.blogspot.com. I have noticed we share some readers.
If you are wondering why surgeons should always have rubber bands around their ankles or how to cook a Thanksgiving turkey in an autoclave my blog has some answers

Pam said...

Way to advocate for your patient and your RN practice.

salsabike said...

Thank you, thank you, thank you.

Tommiegirl G said...

Dr. DeSade: "I want to write this nurse up for unprofessional behavior and for questioning my orders!"

Wonderful Marvelous Fabulous Jo: "Just make sure you spell my name right."

Me: "YESSSS!!" *Fist pump* "Stick it to him, Girlfriend!"

I have dealt with a couple of those lovely individuals with Seriously Overinflated Doctor Type Ego, and it delights me to know that there are nurses like you doing their best for us on the daily. Keep swinging, Jo!

Diane Baltzell said...

Great to hear that you advocating for your patient against doucebaggery was supported! Another reason, although less important than patient comfort & safety, is that TEE probes are murderously expensive. Repairs after a patient bites one are upwards of 10k.

Comradde PhysioProffe said...

Whoah! What a goddamn fuckehead!