Archive for February 9th, 2010

!La Penultima!

So when we were living in Spain, my parents were fond of a tradtional toast. Every new drink was toasted as “!La Penultima!” (the second to last). I’m kind of feeling that way about the hospital. I came in on Wednesday for “a few hours of monitoring” and ended up being admitted “for 24 hours”. Then all hell broke loose and I landed myself on Mag Sulfate for a day and a half, and they said they’d probably try to let me go Friday. Friday they didn’t let me go b/c I was still contracting and there was the impending snow. Saturday they said “just one more day.” Sunday they said, “Just one more day.” Yesterday they said, “just one more day.” I feel like I’m on my perpetual penultimate day of this almost-week-long hospital stay. I’m frustrated, and I’m sure Seth is even more frustrated. I’m tired. I’m ceasing to feel confident in the medical care I’m receiving (I think the DOCTORS have been totally on top of things – but the nurses are… not always, and THEY are the ones providing most of the direct patient care.

This takes me back to that one summer I spent in North Carolina in summer camp. I was miserable there, not because camp wasn’t good and not because I wasn’t learning a lot. But the people. The other campers in particular… It was just too much to be cared for by strangers for that long. I just wanted to go home. And now? I just want to go home. I really hope today isn’t another penultimate day in this endless stay in my hospital room.

I wouldn’t care so much about being here for days and days on end with no real definitive timeframe for parole, except that the longer I’m here, the more things that are falling through the cracks. Or maybe they’ve always been falling through the cracks and I just didn’t notice in the first few days. Either way, the devil is in the details, and no one here seems to be a devil worshiper.

I’m tired of whining, but there’s also a piece of me that feels like some of these things ought to be documented. So that when I look back on these things I’ll know that I wasn’t just being a hormonal, over-reacting pregnant lady. Or maybe so that when I look back on things later I’ll *know* that it was actually just me being a hormonal over-reacting pregnant lady. Most of the nurses here are very nice, but some are more on top of things than others. Many of the nurses can relate to aspects of my pregnancy – several were also on terbutaline pumps, zofran pumps, bed rest, etc. Somehow, their ability to relate doesn’t translate to consistent care, but hey, at least they’re personable, right?

When I was admitted on Wednesday, I made it clear that my PICC line hadn’t been flushed with heparin yet that day and that it needed to be flushed with heparin at least once every 24 hours. Nurses kept telling me that it did NOT need to be flushed with heparin, particularly if continuous fluids are running through it. That’s a nice theory, but I know from experience that when that PICC line wasn’t flushed at least daily, sometimes more, the line wouldn’t run very well. Nevertheless, the answers I got were “we don’t do that” or “you’re wrong.” Needless to say, it turns out that I know what I’m talking about. No one could get a blood return from the PICC line, and it stopped running very well, and ultimately became completely occluded. When I spoke with the IV Therapy nurse who replaced my PICC line with a new one (a saline-only flush), she was appalled that they didn’t at least flush it with normal saline 1-2x per day. When she pulled out the old PICC line, she could see that a fibrin sleeve had formed over the end of it. This is a common issue that happens with most PICC lines eventually, but had it been flushed regularly, it might still be working.

Yesterday’s day-shift nurse was nice enough. She, too, had been on both Zofran and Terbutaline pumps during her recent pregnancy (she has a 4 month old). She had the same primary nurse from the home health care that I’ve got. She empathized with the whole “not eating” thing. But she was also really flaky. When she hung my new IV Fluid bag in the morning, I told her I typically get a banana bag in the morning (IV Fluids with multivitamins for infusion, thiamine, pyridoxine, and folic acid). She said she’d look into it, but I never heard about it again. My OB had wanted me to stay in the hospital at least through Monday so that I could get my 17-P injection, so I had Seth bring in the injection and I kept telling her it was there and saying I needed it and she kept saying “oh good!” But I never did get the 17-P injection.

I have an order for 25mg of Phenergan every six hours. It took a few days to convince the nurses that this is a scheduled, not PRN, medication, so at least she got that part right. But I didn’t have a working PICC line until yesterday afternoon, so the Phenergan was being run through a peripheral IV that they had put in on Saturday. Phenergan is extremely caustic to the veins, so it can’t be pushed directly into a regular IV (though it can be pushed through a PICC line); it is supposed to be diluted into saline and dripped into the IV slowly. My orders are for 25mg of Phenergan in 100ml of saline infused over 30 minutes (200ml/hr). The nurse ran the Phenergan through at 999ml/hour – FIVE times what it should have been. I was in tears from the searing pain up my arm. I kept trying to tell her (and others) how much the line hurt (I’d actually tried expressing this for days), but I kept getting told that IVs in the hand are ALWAYS painful and that Phenergan is ALWAYS painful going in. Call me a skeptic, but I’ve always heard that once it’s in place, IVs shouldn’t hurt to the point of tears. I told Seth about the infusion rate and he said that’s just plain not SAFE. Yeah. Plus, hello? It hurt! When the IV therapy nurse came in later they had just started running ampicillin through my peripheral IV and I was near tears from the pain again. The IV Therapy nurse stopped the infusion, moved it to the working part of my PICC line, and pulled the line out of my hand. I realized then that my hand was swollen to 4 or 5 times its normal size. The vein had sprung a leak and fluid (painful, caustic fluid) had been leaking into my hand. (the swelling has gone down since, for what it’s worth).

Yesterday evening I was sicker than I’d felt since getting admitted to the hospital. In fact, yesterday was the first day that I’d thrown up since being in the hospital (I rarely go a day without throwing up – but since being in the hospital I’ve made no attempt to eat food and I haven’t moved out of bed – moving always makes me sicker). It turned out that although my medication order is for 25mg q6h, the nurse gave me 12.5mg of Phenergan. Normally, I’d be really annoyed about this, but it turns out that the hospital policy is that no more than 12.5mg may be given at a time because it is so caustic. While I think the hospital policy is stupid (there’s no reason they couldn’t just dilute 25mg in 200ml and infuse over an hour – that would have the same effect in terms of dilution to avoid the dangers of the drug in small veins), I am fine with the policy being enforced. I am *not* fine with it being enforced willy-nilly. How is it possible that in six days only one nurse picked up on the fact that the order wasn’t written per policy? My doctor this morning was willing to rewrite the order to 12.5mg/q3hours if I need to stay, so that is also a reasonable workaround that is compatible with the hospital policy.

Just as frustratingly as the Great Phenergan Snafus of 2010, was yesterday’s MVI snafu. I’m supposed to receive continuous IV Fluids at a rate of 125ml/hour (which boils down to about 3 liters per day). In one of those liters of fluid, they are supposed to add adult multivitamin for infusion (MVI), Folic Acid, Thiamine, and Pyridoxine (also known as a banana bag). I’ve been getting the MVI bag in the mornings, but as far as I’m concerned, I don’t care WHEN I get it, as long as I get it. Since I’m eating nothing, this is the only way I’m getting any vitamins in me at all. Yesterday when the nurse hung my first bag of the morning, I noted that it was just plain D5LR – with no MVI (it’s easy to tell – the bags with vitamins added are flourescent yellow). I let the nurse know that I typically get MVI in the morning and she said “Oh, okay, well, I’ll go check your chart,” but I never heard about it from her again. Normally the shifts here are 7-7 and 7-7, but for whatever reason, I had a different nurse (Nurse Ratchet – stay tuned for an entire post about her alone!) from about 4-7 yesterday bridging the gap and when she came in to hang a bag of fluid, I noted again that it did not have the MVI and I told her I hadn’t gotten MVI yet. “You get that at night.” No, no I do not. “well, I’ll check your chart, but I was told in report that you get that at night.” I don’t give a crap WHAT she was told in report, I’M the one who’s been here for nearly a week and I’m the one who’s seen how often and when I receive various medications. I’m pretty sure I know the routine by now. When the night shift nurse came on and hung a new bag, I noted again that I still needed an MVI bag. “I’ll check your chart.” Only this nurse DID check my chart – and she came back and said, “You’re supposed to get the MVI in the morning.” Yes. That’s what I’ve been saying all day. Well, the bag they had was expired (you can’t premix these bags too far in advance), so she said she was working on getting a new bag from the pharmacy. I finally got my MVI bag this morning – meaning I went a full day (with three different nurses) without any MVI. If I were eating ANYTHING while I’m here, then it wouldn’t be that big of a deal because obviously food has vitamins and minerals and you know, other good stuff. But obviously, that’s not the case.

Nurse Ratchet was in a league of her own, and deserves her own post. But the long and the short of it is that I got a visit from the charge nurse today after I nearly lost it on my nurse this morning.

The good news is this: My OB came in this morning and said she was inclined to keep me here in the hospital for another couple of days to get me through this next snow storm. I told her that if there was a clear medical advantage to me staying here, I would do whatever she recommended, but if she was still on the fence about it, I’d just as soon go home and see my kids. She conceded that I could go home, and noted that if I need to return to the hospital in the middle of the snowstorm, I should simply go to HC (which is five minutes from my house vs. this hospital which is 30 minutes without traffic or snow). My OB doesn’t have privileges at HC, but better that I get to a hospital safely and receive appropriate care from a hospitalist or resident on call than risk coming out here and getting into an accident. So I get to go home today and no more torture by nursing staff.

I’ll write more about it later, but I *did* speak to the charge nurse today and she had a very appropriate and acceptable response.

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