Lost on the Floor

Just recently I wrote about the healing environment of a hospital (you can read it here). I think I got the point across that I'm not a huge fan of doing this just to make it "bigger, better and more luxurious." Lately, due to the expanding coverage of environmental issues, thanks in part to "An Inconvenient Truth" and recent Earth Day, environmental issues have been on my mind. I took stock of my own personal carbon footprint and realized what I was doing and how I was contributing to making the problem of global warming worse. Then I got thinking further.

According to Health Care Without Harm, an organization that is trying to bring "greener" measures into health care, hospitals generate over 2 million tons of waste a year, not to mention the environmental footprint large institutions create. That is more than quite a bit. As I began looking around for more info, I realized that while people are starting to care, it isn't enough. So I began looking locally. Two local hospitals have either been built in the last 2 years or had major additions. One is actually LEED certified, meaning it has been certified as a high performance green building. The other does not seem to be. That hospital, Southwest Washington Medical Center, which was the genesis of the previous blog post, appears to have gone to the bare minimums to create in addition to a healing environment, one that heals its environment. It was far more important to create a "resort" style experience than one that also makes less of an impact on the local environment. As for waste, there doesn't seem to be an accurate accounting, but from working, I know we create a great deal of waste. We use products made of PVC, laced with phalates, coated with BFRs, relying on single-use non-sustainable products. I know many things must be single-use only, but some do not have to be. Not to mention the chemicals we use to clean and the bio-hazardous waste our patients create. I figure there has to be a better way.

Many talk without practicing what they preach. While I know that it will take time and effort to change where I work, I can do thing sin my life to help. I figured that the things my wife and I have done already will reduce our greenhouse gas emissions by over 4 metric tons a year if we continue on the road we have started down. I wonder how much of an impact could be made by large health systems trying to do the same?

-end Public Service Announcement

I've been having a bit of an almost existential crisis regarding work. There are days I feel like there is not way I can continue, that I chose the wrong profession, that I suck at my job and feel like there is no way on God's green Earth that I'm going in to work. I have yet to call out, just to call out, but there are days when I feel that it is what I have to do. But I go on. There are events that contribute to this feeling, then in a wonderful way, prove that I'm doing the right thing, the thing I was meant to do.

For some reason room #66 has it out for me. Of the patients that I've had go south on me to one extent or another have been in that room. Something abnormally high like 90%. I'm about ready to stop accepting assignments that include that room, it's got my number.

And that's where he was that night. Hanging out in his room with his wife. Came from an outside hospital for an angio due to increasing anginal symptoms. Cardiac history? Check, the thing was as long as I am old. Not pretty. CABG x4 last year, CHF, HTN, elevated lipids, smoker...at least he wasn't diabetic. Plus, he was young, at least relatively so. I got in report that it looked like 3 of the grafts had closed off completely and the fourth was pretty occluded. He was doing OK, his last bit of chest pain had been controlled with nitro paste and morphine. The docs didn't know what to do, really what can you do?

He was stable, blood pressure a little on the high side with a splitting headache from the nitro. So I did my nightly nursing thing. Kept my eye on his pressures all night, watched his heart rate and rhythm on the monitor at the nuurses station and let him sleep. I'm doing rounds at 0400 when his wife calls out to the nurses station that he's having severe chest pain, worse than before. I hit him with MONA, nothing. DOesn't even mae a dent in the pain. BP is way up, HR too. One of my colleagues gets a 12-Lead EKG, I'm calling the doc. One thing that sucks about nights is that a doc is a little harder to get hold of. Finally get hold of him, get new orders. I'm feeling a bit frantic now. I'm hoping this fear does not show on my face or through my actions. I'm already getting tired from having to run down the hallway from the med room and phones. His wife is really getting agitated now, she's questioning if coming to our hospital was the right thing, if I was the right nurse for the crisis.

Give him Metoprolol x3...maybe that will bring down the BP and rate, ease off the oxygen demand of the heart, maybe help to bring down the pain. Nope. Barely dents his BP or rate. I've got a nitro drip running now, it's helping a bit, but not much. Mind you he's also getting morphine and extra sublingual nitro, anything to get this pain under control. I keep upping the rate of the drip, anything at this point. His wife, well, she's very upset now. She doesn't see a doc around, wants to see one, even though it is 5am and any sane cardiologist is asleep at this point. I'm doing what I can to calm her down, calming myself at the same time. His BP and rate if coming down now, but the pain is still there, he's calling it 9/10, nothing seems to be working. I max him out at the level we can give on my floor. I'm calling the doc back saying, "We need to go to ICU." Luckily, he agreed. Thankfully, I had kept my charge in the loop to what was going on and as soon as the doc said to ship him, we were ready to go. After 3 hours of fighting on the floor, we shipped him to the Unit.

It wasn't what I did, or didn't do that shook me so hard, it was the things that his wife was saying. I know that it was a stress reaction and that I was doing everything I could do, but it still hurt. Here I was trying to save her husband's life and she was still calling me incompetent and that our hospital and floor was worthless. And those were the nice things she was syaing...it was not pretty. Looking back, I probably would have changed the sequence couple of things and tried to get him to the unit earlier, but I know I did my job right that night. Funny thing though, the 12-Lead we ran, didn't showed anything different from one previous in the day. When I got in the next night, I looked at his labs. There it was, jumping off the screen at me: Troponin I: 5.82ng/ml. His cardiac enzymes had literally gone through the roof. It wasn't a small infarct, it was the big one.

Lucky for me, I had a couple of nights off after that. Time to forget and forgive. "One day I will get the hang of this," I told myself. My shattered confidence was slowly coming back, I was feeling better about it all, not great, but OK. Then I the other night I saw a familiar figure. "No way," I thought to myself. Sure enough it was the very same guy. Up walking in the halls. Pink, warm, talking and walking. He had survived a serious infarct. He said the docs figured that night, the last of the open grafts shut off, leading to his pain and infarct. He told me he appreciated everything I had done for him that night and that he knew that I had done everything I could to help him. Talk about shock. I was amazed, in shock and nearly speechless. He thanked me again and we went back to our night.

Crisis not totally solved, but I do feel much better about work. I know I chose the right profession, it's just taking time to really feel like I'm actually getting it. I know I am and when I have a night like that, I feel it. But seeing the positive outcome afterwards made me realize why I chose this in the first place: to help people.

Sure I'm still Lost, but I'm finding my way. It's what I'm meant to do.

I saw this story titled: "Hospitals Designed to Heal" on line this morning as I awoke from the slumber of a man exhausted (this is the last time I stay up all-day after the night shift...family first though). While I agree in concept that hospitals are places to heal and that they should provide a healing environment, there are limits to that.

"Southwest Washington Medical Center in Vancouver built its new hospital tower with many design features as comforting as you'd find at a resort hotel." I found the words "resort hotel" particularly ominous. In creating a resort, you place in the patient mind set that this is a vacation, thus they should be served hand and foot, as if they were on vacation. Granted, not all patients will feel this way, but many, and their families will. I am a believer in the active participation of the patient in their health care, if able. That's why I will try to get patients to do things for themselves. Yes, I will be by their side every step of the way, but I will make them do it themselves, again, if able. As an example: we post-CABG patients 2-3 days our of surgery on our floor. These folks need to start moving soon after surgery to reduce any number of complications. We push them, yes, but when they go home, we will not be there to do everything for them. We want to get them out quickly to reduce the risk of obtaining a nosocomial infection or other nosocomial complication. Coddle we don't do. Nurse them, we do. We encourage active participation. If you're on vacation, do you really want to work?

I do understand the importance of quality design and eye-pleasing decor especially when faced with research like that done by Roger Ulrich where he "compared abdominal surgery patients assigned to rooms identical except for the window view: Half overlooked a grove of trees; the other half faced a brick wall. Patients with the tree view recovered sooner, suffered fewer complications and needed less pain medication than wall-view patients." There should be limits though. Do we need to spend millions and millions of dollars to draw patients to one particular hospital? How about when that money is at the expense of current facilities? One colleague related to me a story of the expansion of the Legacy system in Portland into nearby Vancouver, WA. He related how the project for the Salmon Creek hospital went way over budget and how the system diverted money from where it could to make up the shortfall. It meant no extra shifts, reduced staffing, no sitters unless absolutely needed, no new equipment, reduced availability of working equipment, all to create this Valhalla-esque hospital with Italian tile floors in the main lobby. Sure, they operated within acceptable limits, but bare-bones. While he may have had an axe to grind, it made a point to me.

One thing I do believe a great deal in is private rooms. At one point during my time in Arizona, my wife ended up in a hospital and there shared a room with 3 other women. Yes, 4 post-partum women per room. Not cool. Not even close to peaceful, much less anywhere near private. HIPAA was non-existent on this ward. We heard all about how one roommate had Hepatitis C and gang bangers coming after her. A private room would have solved this problem. Semi-privates do work, but still you have to basically live with someone else while in the hospital. What if the roommate has an overbearing or overly large family? Or is a moaner/groaner/screamer/yeller? Not exactly a peaceful healing environment.

Finally though, it comes down to money. Like so many things in life. If the hospital presents a pleasing face, more people will choose to have care there, which equals more money for the hospital. Elective surgeries are where the money is in our health care environment. If you don't get that business, you don't stay in business. Considering that one drug-eluting stent costs around $4,500 not to mention the cath lab, the post-procedure room, nursing and ancillary staff and of course the doc, you can see how it can add up quickly. And this is a simple stent. What about a total hip or knee? Yep, big money.

Contained in the article, although along a different train of thought, was this gem of a thought:

"A study last year by Randall Pozdena, an economist with consulting firm EcoNorthwest, estimated that the metro area has about 1,500 surplus beds. Considering projects planned or under way, the economist projected that unused capacity will expand to 2,208 beds by 2025. That's assuming the addition of 2.2 million residents and a doubling of residents older than 65."

I'd love to know how they figured this one. When we're full nearly every night, it is hard to fathom. I know that is metro wide and that we're not the only floor at my hospital, but it seems very often we have the last bed in the joint and it gets filled quick. Maybe it's all about location, but I don't know. It's an interesting idea to chew on.

Is there an answer? Not really. What would I love to see? Let me show you:
I see a place where it is nice, but not like a resort hotel, more like a 2-star one. Nice, with the necessary amenities, good TVs, internet, decent food. We have plenty of staff and working modern equipment. The patients are polite and pleasant as are the families. We don't have to fluff pillows or pick things off the floor for capable patients. The nurses have a 3:1 patient to nurse ratio, CNAs that do their jobs, colleagues that don't call off for no reason, plenty of staff parking and a coffee cart open all night.

A guy can dream can't he?

According a new article published by the New Scientist on Monday, a new group of enzymes have been found that effectively remove the cellular antigens that are the basis for blood typing. In easy words, they turn any blood type to Type O, which anyone can receive.

Sure this is not going to solve the problem faced in health care due to a lack of blood and blood products, but it should make an impact. The arena where this will probably be seen the most will be in the field of trauma resuscitation where it is not uncommon to burn through tens of units of blood, if not more, in a trauma situation. I think the most blood I've been on-hand to see given when in an ICU as a student where we gave 6 units of PRBCs plus a six-pack of platelets during the 6 hours I was on the unit...which really is nothing. Most I gave in a shift was only 3 units, over a whole 12 hour shift.

The other flip side is that it does nothing to address problems of plasma and platelets, two other common forms of blood products typically given in the in-hospital setting. But, it is progress.

It's like the ubiquitous order of a Diet Coke after the "Double Quarter-Pounder Meal."