All Intensivists Are Not Created Equal

All Intensivists are not created equal.

By: Debbie Moore-Black, RN

I’d like to preface this story with saying that the majority of the Intensivists I have worked with have been exceptional, caring, and professional. We had all established a good camaraderie and we had mutual respect for each other. We worked well together.

But there always seemed to be one that was the exception.

And as I drive some long miles on a recent “get away” to the mountains…, the flashback came back to me.

Joellen was 64 years old. She smoked all her life. 2 packs of cigarettes a day. She started smoking at the age of 16. Hollywood made smoking sexy and romantic.

By the time she was in her late 50’s she developed severe shortness of breath without exertion. She had difficulty breathing. She wouldn’t put her cigarettes down.

Her physician told her: “If you don’t stop smoking for good, you’re going to die.”

In and out of the hospital she progressed to a diagnosis of CHF and COPD. Her physician told her at the age of 64 she was now considered “end stage” COPD. There was no regimen of care for her as her lungs were destroyed by her incessant smoking.

She agreed to sign a Do Not Resuscitate as she entered the ICU one last time. She did not want to be intubated. But she agreed to be medically treated.

It was now my shift. Night shift. And Joellen had a very bad day. Her breathing was shallow, her lips were cyanotic, her O2 sats were in the 80’s.

It would have been an optimum time to place her on “Comfort Care”, but the patient said she wasn’t ready to die.

Throughout the night, I watched Joellen breathe with great painful effort. She sat straight up in bed, shallow forceful breathing.

She suffered so.

I notified the “Virtual MD” to request morphine for Joellen. She had nothing ordered to ease her breathing. Even a small amount Morphine IVP could help relax and slow her breathing down without as much struggle.

The virtual MD said “no” he would not order morphine for her. I explained how she was awake and alert and suffering terribly… but he said “no, I don’t want her to get addicted to the morphine.”

I then Notified the Intensivists on call.

That was our chain of command.

Before I could explain myself to the Intensivist on call, he said to me “Do you realize you woke me up from my bed at 0300”?

I told this physician how Joellen was having shallow breathing, diaphragmatic breathing, low O2 sats and she was suffering greatly and all I wanted was some Morphine to give to this poor lady to ease her breathing and her suffering.

He let me know he would get back to me after he talked to the Virtual MD.

One hour later, I received a call back from the MD on call. Lasix 20 mg IVP stat. That will take some fluid off of her and it will help her breathing.

We don’t want her to become addicted to morphine”

And that was his answer.

And here I was faced with a dying woman. Lasix didn’t touch her. Her breathing became more shallow. Her lungs filling with fluid, barely able to auscultate. Her O2 sats slowly dropping to the 70’s and 60’s.

I sat next to Joellen and held her hand. Wanting to breathe for her. Wanting to comfort her…wanting to provide her with just a small amount of morphine…. but unable to.

I was given the most inappropriate order ever from 2 MD’s who claimed a dying woman would potentially become addicted to morphine.

Poor Joellen. As I held her hand, her breathing slowed to a minimum. She had worked so hard. Her eyes rolled back, and she let out her last breath.

I felt defeated. That a simple order from an MD could not be obtained.

Joellen died a painful death.

Eventually I found out that there was a review of this “case”.

I’m sure there was a “mild reprimand”

I drive up to the mountains. The leaves changing into their vibrant colors…

And I still see those haunting eyes of Joellen.

The patient with a pocketful of IDs

Originally published on KevinMD

All of us nurses and physicians in the ED and ICU knew him well.

He was a young, 21-year-old. A smart, articulate guy who kept going from one hospital to the next. He had a system down … almost.

This young man was a drug seeker. He knew all about seizures and how an Ativan IV push felt during the “seizures” he allegedly was having.

Even though he had several identities and different names, we knew exactly who he was. He would wait for an ICU nurse to assess him at the beginning of the shift.

After the nurse assessed this seemingly charming man, she’d exit his room but wouldn’t get too far from the door when she’d hear shaking from “Randy’s” bed. When she’d turn around, she’d see Randy in a full grand mal seizure. A chaotic quiver, clenched teeth, followed by rigid body and blank stare.

Damn. He was good!

His physicians were fooled for quite some time. They’d give him the EEG, the CT scan, and then the Ativan IV push … and the old standbys Dilantin and phenobarb, too. But “Randy” preferred the combo of Ativan and attention the most.

Eventually, he was diagnosed with “pseudoseizures,” which are not the same as a seizure. There are only two types of seizures: epileptic and nonepileptic.

We knew him well.

Epileptic seizures occur when a sudden electrical disturbance in the nerve cells in the brain causes the person to lose control of their body.
Psychogenic nonepileptic seizures (PNES), are seizures that occur as a result of psychological causes such as severe mental stress.

Pseudoseizures may be caused by: anxiety, OCD, panic attack’s, ADHD, traumatic injuries, ongoing family conflict, substance abuse, PTSD or physical or sexual abuse.

How do we treat of pseudoseizures?

Cognitive-behavioral therapy (CBT).

There was a conference: Randy and the intensivist. The doctor explained to Randy that his seizures were not from a neurological disorder. But the seizures he had developed were after multiple or acute stressors that overwhelmed his coping ability.

Randy was angry. Though he had many stressors in life, homelessness, non-compliant with his antidepressant medications, no-shows with therapy, Randy refused to listen to the doctor.

And so he continued aimlessly jumping from one hospital to the next — a new name for each hospital. No family. No home. An aimless wanderer.

Police found a young man in a fetal position at a bus stop. A tourniquet wrapped tightly around his arm. An empty syringe in his hand. Heroin.

Dead.

And with a pocketful of IDs:

Randy, Scott, Jeremy, Michael, Tim, Ryan.

We knew him well.