So this MICU shift was very difficult after all, and it wasn’t for the reasons that I suspected. I thought it would be the tasks that got me down, i.e. not enough time to get things done. Surprise, surprise, turns out it was the patients.
Imagine a patient with End Stage Live Disease. She currently has hepatic encephalopathy and suspected GI bleeding. She was recently extubated. They usually put an oral gastric tube in and then yank it out at the same time when the patient is extubated. But then the patient continues to have this hepatic encephalopathy, which is a Catch-22 because then she is unable to swallow her lactulose, (which would help to restore her mental status.)
You attempt placing a nasogastric tube, twice, both times unsuccessfully, both times with the patient screaming at the top of her lungs. So at the end of the day, her baseline mental status hasn’t returned, and you have no way of giving her nutrition or lactulose. But she isn’t sick enough to stay in the ICU so you transfer her to the floor.
Typical situation for this disease, I tell myself, and that’s just the way it is. But I feel so frustrated, and so helpless for two reasons. (1) I CAN’T GIVE THIS PATIENT HER LACTULOSE AND THAT IS THE ONE THING THAT WOULD MAKE HER BETTER and (2) Trying to place this NG tube when she is not mentally stable enough to cooperate is very traumatic to her. And inevitably, the docs will always order a lactulose enema out of desperation. GUESS WHAT? If your patient can’t swallow a cupful of medicine, you can be damn sure she won’t be able to retain a pint of lactulose IN HER BUTT. So that never works.
The weird thing is that even though I hadn’t worked since last August, I had the exact same patient scenario: Liver Failure, recently extubated, mentally, in liver land, and unable to swallow lactulose.
Is it a failure of our healthcare system?
Is it a failure of my nursing skills to place an NG tube?
Is it a failure of our normal routine to yank out the OG tube when extubating?
Is it a failure of medicine in that we have failed to discover a better way of reducing a patient’s ammonia level (which is what lactulose does)?
In the end it doesn’t really matter because it was a failure, and I left that day feeling like I had done nothing for my patient except cause discomfort, and transfer her to lower level of care.
One thing is for sure, I vow never to complain again about working at Chez Recovery. It took a shift back in the MICU to make me realize just how good I had it there.