Dennis Quaid and consent-oriented care

We just watched a video on the Dennis Quaid twins heparin error (we've seen umpteen of these during nursing school, but this apparently is new), where they received adult (1,000 units per ml) doses instead of pediatric doses (10 units per ml). This time something occurred to me that hadn't before. We don't explain medications and dosages enough when we're administrating them—if at all. That might have prevented this error, since apparently they were present for one of the doses. If a nurse had to explain what he or she was giving, they might have checked twice at the label. But maybe not.

When my wife and I had midwives for our births, they were very consent-oriented, much more than hospital staff ever is. They asked if she wanted to take things. They recommended rather than commanded. They explained mechanisms of action and effects. The biggest contrast I saw was with vaginal exams - do you want one? It's okay if you don't. Of course, a midwife doesn't have the same necessity of documentation, patient load, and having to give status reports to the OB, which prompts her to say "I'm just going to do a vag exam now"—in effect, obviating consent. Every day I see nurses who say "I have your meds now" rather than framing it as a question or waiting for an answer, or even doctors who obtain consent without really waiting for a yes or a no. We unofficially bypass consent a lot in nursing—I know from experience it's easier to get someone to take a med or have their blood taken if you simply state you'll do it, instead of asking. We have to in the hospital environment. But I also see lots of minor errors, such as drawing blood on the wrong patient, and I've seen some major ones, including heparin overdosages and Coumadin overdosages. If hospitals allowed us to make our tasks human-centered rather than documentation-centered and high-patient-load-centered, that would help avoid errors like these.

I know we're too busy in the hospital to do this. You can't play the home midwife with seven sick nursing home patients and their crazy families on the hospital floor. But I think ideally we should center our med administration around patient (or parental or power-of-attorney) consent rather than just trying to get them all passed as quickly as possible. Of course, that means lower patient loads for nurses, which is another whole ballgame.

Confusion after anesthesia

I took care of an older gentlemen who had a laparascopic procedure and, upon wakening from anesthesia, became confused and combative and had to be restrained with soft wrist restraints. At post-op day two, when I was with him, he was still screaming and thrashing around—not combative, but wanting to pull off his cardiac monitor and IV and leave. Over the course of the day he became more lucid, then more confused. His main focus seemed to be the restraints, so at one point we took them off and he became quite calm...for about two hours. Then he went bonkers again, so the nurse restrained him.

The last patient I had who experienced confusion after anesthesia was a younger woman who had heart surgery. Day one after surgery she was fine (albiet groggy), but day two she was screaming, paranoid, thought we had arrested her, and throwing things. Post-op day three she was back to normal and didn't remember any of it.

And then there were the few patients who stroked during or after surgery, or seemed to have permanent mental status changes, or have other negative sequelae after anesthesia. One older patient I took as a care aide on the medical floor had been combative and tied to the bed after surgery, but had improved. When I got him up for physical therapy he threw a clot and had a pulmonary embolism. We coded him and he died later that day.

So with all this on my mind, I came home to find my daughter had received a new book: Gaspard in the Hospital. It's about a little dog who swallowed a keychain and had to be put under anesthesia to have it removed. During the anesthesia he dreams he's a race car driver, and when he wakes up his mom gives him a present. I explained anesthesia medicine to her, and ended with saying that you wake up fine. She looked at me and said "Always?" I said something like "Uuuhhyyyyeah." Probably not reassuring. But then again, don't kids do better than adults with anesthesia, and surgery in general? Something I should look into.

Vaginal C-sections: Tearing During Birth

One thing that truly surprised me in my maternity rotation was the number of women who tore during the delivery. The majority of women we saw had perineal lacerations, labial lacerations, vaginal lacerations—and the average weight of their babies was six, maybe seven pounds! It astonished me. Not to toot my wife's horn or anything, but our last baby was more than eleven (11) pounds and she didn't tear. I wouldn't suggest starting at eleven pounds. We worked our way up to that weight through four children, but still, our first kid was over eight pounds.

An eight pound baby in the hospital is expected to have caused lacerations—if not a c-section. Midwives don't have this attitude, and they don't come to expect this in their practice. Why?

Because position and pushing matter: how the woman positions herself, and how she pushes during delivery. All of the women we saw had to labor and deliver on their backs, and were "coached" (or hollered at) to bear down regardless of whether she had the instinctive urge to push. Women are put on their backs, regardless of what position their body tells them to be in, and despite the fact that we know that the sacroiliac joints can't open up in this position. Supine delivery increases the likelihood of a difficult labor, shoulder dystocia, and a forceps or vacuum extraction. And women are yelled at to push despite the fact that we know there's an actual reflex that prompts the woman to push when the fetus is descending properly and smoothly. All I could think was that if the women we saw could labor in whatever position they liked (read: obstetricians and nurses weren't afraid to get down and catch babies in whatever position they're coming, like midwives do), and they could push when they want to push (with eased guidance from a tearing-conscious practitioner, rather than a shouting person who's worried about lawsuits), we would not have seen so many tears.

It's not a small deal. One of my patients had to be sewn up for an hour (for a six pounder). I wrote in my journal about another patient's horrible tearing:

The nurses were so busy today. One shouted that she needed a Foley urine catheter taken out and would a student like to learn to do it. I finally volunteered, not to learn but because I already know how to from my job. It turned out the patient who needed the Foley out was the poor young lady who another student had yesterday - she had described an episiotomy and horrible tearing - what the teacher said they unofficially call a 'vaginal C-section'. We had asked how big the baby was, and it was only six pounds. The nurses are like "The poor girl's never going to sit the same again." So I go into the room, tell her what I'm going to do, that it's fast and pretty painless, that it can be done without really uncovering anything, and then I wash my hands and put on gloves. When I come back to the bedside, the girl is SOBBING. Completely crying and shaking. She was so afraid it was going to hurt, because of how she had already been hurt. I was so upset after that. They completely butchered this girl, as far as I feel. It's her first birth. She'll spend her whole life remembering this.

Of course, my wife is telling me it doesn't matter—I could prove that forcing women on their backs for labor and delivery actually kills people, and doctors still wouldn't stop doing it. You need to be on your back for the EFM, and for the safety of your baby (read: the convenience of the staff).

On the other hand, the epidural patients can't get out of bed, and have no urge to push—and now that I think of it all my patients with tears had epidurals.

The Get Out of Hospital Free card

I need to contact my insurance company and see if I can obtain a dispensation to sign out of hospitals against medical advice (AMA) without penalty, should I ever be admitted to one.

A patient was discharged by his cardiologist the morning after a cardiac cath procedure. The nurse did not tell him this and waited the entire day for his primary care physician to round and discharge him. Problem was, the PCP didn't know he was in the hospital. Often patients come in the ER with chest pain, go to the cath lab, and get discharged the next day, all under the care of their cardiologist, without their PCP getting involved. So by 5 pm the nurse decides to call the primary, who says to discharge him and she's not coming in. We call a taxi for him because he's not supposed to drive. By 6 pm she has his discharge papers ready, and has me escort him to the pharmacy to pick up his meds. Except by now the pharmacy is closed. And he missed his taxi. It was mind-boggling.

A few days before we had a chest pain patient who was discharged in the afternoon by his cardiologist. But by that time, his primary was off call. Another doctor was covering, and he didn't want to discharge him and told him to wait until morning to talk to the primary. He came in for chest pain! If the cardiologist discharges him, what else are we looking for? The head of critical care even got involved, but to no avail. No discharge. He had to occupy a $2,000 bed for one more night because the on-call was only thinking about lawsuits.

So I need an AMA card to sign myself out if I ever think it's necessary. It'll save the insurance company money!