The fourth day of a hospitalization is probably the worst. It's official, you've spent half a week there. You've slept poorly (no such thing as a full night's sleep at a hospital), been poked and prodded, eaten food from passable to awful, and dealt with the structural imperfection of the hospital hierarchy.
Never mind that it's Sunday afternoon, and you're about to enter the Long, Dark, Tea-time of the Soul. That last bit, the hospital hierarchy, and the shared responsibility of the specialties is the real curse of hospitalization.
But have patience with it, patients, because it is (mostly) better than it used to be. On the whole, there are better outcomes, but the flip side of the coin is longer stays. Exercise your patients' patience, because the paternalism of old has made way for patient consultations, acceptance and understanding of risk, and a generally greater requirement for the patient to participate in their own treatment and care.
Let us return to our hypothetical patient who was admitted to the hospital via the Emergency Department. The patient with a non-emergent, but urgent healthcare requirement. In that case it was low hemoglobin, dropping RBCs, and trending lower WBCs/Neutrophils. Once admitted and on a hospital floor, she gets a bunch of blood products. The doctors and nurses continue to follow up on secondary complaints, like a heavy, off-cycle menstrual period, and generally worsening fatigue. Your patient and caretaker did well by coming in, because it certainly would've been an emergent condition by now.
She's seen by a bunch of doctors. The ob/gyns want to stop the bleeding ASAP (to reduce the necessity of more blood products). Switching the patient to a hormone like Provera known to stabilize and reduce uterine bleeding hasn't helped, so they want to perform a uterine ablation (or remote possibility: a uterine artery embolization). The patient is mostly OK with this, as she knows the amount of radiation and chemotherapy she's received over the past seven years or so has likely rendered her sterile. However, the attending (and his resident and intern) want to wait until she's breathing easier because they'll need to put her under either a nerve block or general anasthesia. These are both scary things to do to someone who is anemic with poor oxygen absorption.
Wait, what? Didn't she get a bunch of blood products to help her breathe better in the first place?
Well, yes, but there's a problem. The kidneys can only process so much additional fluid from the body at a time, and when they're made to work overtime to do this, other organs step up (or down) their game with relation to fluids. So, the colon stops pulling so much water out of the feces (nightmarish diarrhea, anyone?) and the lungs and sometimes the various chest cavities can begin to fill up with water (pneumonia or pleural effusion). The diarrhea doesn't bother the attending and his gang so much because they know a fluid bolus is just a bag of normal saline away, besides, there's no hospital in the world that will allow itself to run out of chux pads. The elephant in the room is the one you transfused into the patient by giving her so many (necessary) blood products. Her lungs are fairly wet at this point, so you need to give her lasix to get her kidneys to process that fluid a little faster.
Oh wait, the patient gets really out of breath even just trying to elevate enough to use a bedpan? OK, foley catheter.
Oh wait, she's got scars from prior radiation treatment, and she's swollen from too many fluids already, so the cath takes four or five tries over two days to get inserted.
This is the sort of thing that sometimes results in standard operating procedures and the creation of hospital and/or treatment protocols. In hindsight, the patient (already known to have problems: low SpO2 and elevated heart rate when trying to use bedpans or moving to a bedside commode) could've received a catheter prior to getting the first unit of blood, before the swelling. Reasonably indicated by the shortness of breath on exertion, but nurses and doctors don't like putting a catheter on someone if they can help it, and they especially don't like broaching the subject with someone who is awake and alert. My dear friends, a catheter can save you a lot of misery. I know we're all scared to talk candidly about pee and poop, but let your doctors and nurses know that if the alternative is misery, you're more than willing to accept a catheter!
Anyhow, the catheter is in, now it is a lasix waiting game. Drain the fluids, get the patient's bleeding problem treated by giving her some more platelets until the lasix does its job and they can do the uterine ablation. Poll her CBCs a couple of times for stability, then if she's feeling better, let her go home.
It's a project management dependency game with a bunch of weird little feedback loops in the Gantt Chart. Even though there is still some right hand not knowing what the left hand is doing behavior, hospital hierarchies manage it better than they used to, but it takes time. Remember this and continue to develop your patients' patience, patients.
No comments:
Post a Comment