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Do ICU Nurses Really Have Autonomy?

So today I have an interview at another great hospital in my city, the mental hospital. I’ve spent a lot of time there as a student and was convinced I wanted to do psych nursing. Somewhere along the way I was on monster.com and noticed that Nurse Anesthetists make 100K/year. I also noticed that you need 2 years of critical care experience to even get accepted to a NA program. I thought, hmmm. Well, I certainly wouldn’t want to rule that out, and besides, if I can do critical care, I can do anything, right?

I don’t know if this was such a good idea. Nonetheless, here I am. I know what to do if someone is coding, I know how to titrate pressors, I wean people from ventilators, I can keep a million lab values in my head and spit them back out to you on command but I am weary and unhappy.

This is where greed gets you, I guess. I have officially ruled out the possibility of becoming a nurse anesthetist.

Since contemplating leaving the MICU, I ask myself after every shift, “Are you sure you are making the right decision?” The answer every time lately seems to be a very resounding, YES!

Yesterday I was caring for a 36 year old bariatric patient, very difficult to sedate, had been on the ventilator with ARDS > 1 week. Today the physicians wanted to go the whole nine yards and extubate. They turned her tube feeds off at midnight so she wouldn’t aspirate. Her sedation was cut in half. She did fine on her spontaneous breathing trial so they cut her sedation off completely in hopes of extubating her. I was completely on board with this. If I know what the goal is then I will do anything to try and help achieve it. She was thrashing around in the bed. No many how many times I would boost her up she would slide back down. (Some people just have that kind of anatomy). She was breathing okay, but occasionally setting off the apnea alarm, (you would too if you had all of that sedation on board). The apnea alarm didn’t bother me. I was watching her closely, she was in no distress. She would wake her self up and take a huge breath. I knew that very shortly she would eventually wake up completely and the apnea alarm would go away.

She was satting 97%-100%. I drew a blood gas. It looked identical to the one I drew while the ventilator was doing all the work of her breathing. This girl was ready to fly.

I went to find the physician so we could move to the next step. All I could find was the intern. He consulted with his team and came back and said, “We’re going to have to keep her on the vent and start her sedation again. She needs to have a CT scan. She has had unexplained fevers. and we need to see if there is an abscess.”

“Are you sure?” I said. “I mean, look at her. She is ready to go. And she’s currently afebrile. Her blood pressure is 180/100. It’s not really looking like she’s about to go septic. Once you start getting her sedated again it’s going to take forever to wake her up again. You can extubate her and send her to the CT scan tomorrow.”

AND she had a CT scan 2 days ago, which showed a sinusitis which may have contributed to the fevers.

But I guess at GHOAT we like to be 100%, without a doubt, unequivocally sure. The intern consulted with his team and the decision to keep her intubated was made.

So I gave her hypaque, and attempted to sedate her again. Meanwhile she was continually thrashing around in the bed and now she was pooping all over herself.

After cleaning her up and changing her linens several times (and finally inserting a ‘flexiseal” – flexible plastic tubing which goes into her rectum and collects all of her stool into a bag,) she was transported to the CT scan, and transported back to me.

I checked her blood pressure, it was 80/49. Shit.

The transport tech asked me if we had a MAP goal. (translation: MAP = mean arterial pressure and we use a MAP goal when we are titrating pressors).

At this point I felt like screaming, “No we don’t have a freakin MAP goal because her MAP hasn’t gone below 100 all day long!” (A MAP goal is usually > 60)

But I didn’t scream this because he doesn’t know that, and it’s not his fault.

Instead I said, it’s probably all the sedation boluses she’s been getting. I will turn down her sedation and see if her MAP will go back up to baseline. and of course I will inform the physician of her change in blood pressure.

I turned down her sedation and her blood pressure came right back up to where it was before.

Then the physician ordered to change out her foley because her urine culture was growing something.

Of course it’s growing something, she is laying in stool and probably has been periodically throughout the week. (just to clarify – we do not leave our patients lying in stool purposefully. But think about it. If you are lying in bed, snowed on narcotics, on a ventilator, it is almost inevitable that you will poop all over yourself. And when you are in an intensive care unit, there will be times when the patient next to you is coding, or bleeding out and all of the resources of the unit are taken up by this emergency. You are lying in stool but at that particular moment you are not dying, so you will continue to lie in stool until someone is free to clean you up.)

So my opinion is to get someone closer to being able to control their peeing and pooping themselves. Extubate as soon as possible, don’t fool around, get her sitting up and moving, get her using the bedpan. Please don’t make her lie around in bed sedated on the vent one extra day if you don’t have to.

I don’t know. I think part of my problem is that I’m just too emotional to work there. My instincts were screaming at me that this woman needed to be extubated and that the CT scan was just a CYA type maneuver (or perhaps for educational purposes). I communicated with the doctors, I expressed my opinion. They did not listen to me. And why should they? They have been through many years of medical school and I have not. I have not even been a critical care nurse for very long. They are a team, I am one person. And also, it is their decision to make, not mine. And I guess medical decisions are to be based on scientific data and standards of care rather than instincts and subjective observations (she is buck-wild and ready to reach up and rip that tube out herself!)

I read somewhere that nurses have a very high success rate when predicting whether or not a patient is ready to be extubated.

Is there anything I could have done differently? I went to the intern who in turn went to the resident who in turn went to the fellow. That’s where the final decision came from. I have a feeling that if I went directly to the attending and told him my opinion it may have been taken more seriously.

But isn’t that the just the essence of a bureaucracy? When it takes 5 people to make a decision, and no one can agree so you just sit on it another day. Is that any way to heal ARDS?

But still… there is a tiny little nagging voice in my head that says, “You just don’t have the courage. You don’t have the self-confidence to go up to the attending and interrupt whatever conversation he’s in (because no doctor is ever just standing there doing nothing, it’s always an interruption) and say, “Hey, I really think you should extubate this patient and put the CT scan off until tomorrow.” Because what if you’re wrong? What if they extubate her, and the patient goes back into respiratory failure and then has a difficult intubation (which is quite possible, considering her obesity) and then she dies or is brain dead (I’ve seen this happen on my unit – Did I mention that she’s only 36?).

So when I am telling you this story, I want you to get something from it:

I respect the doctors. I respect their experience and education, and I respect the fact that when they make a decision, a person’s life is on the line. They have to live with that. I can throw my 2 cents in but ultimately, it’s not my decision, nor should it be.

Personally, I just don’t think I’m cut out to work in an environment where doctors write orders, and nurses carry them out. The MICU at first glance, appears to be a place where nurses have autonomy (it was presented to me this way in the beginning because we use “protocols” rather than going to the physician for each and every order) but in the end, we really don’t have much autonomy. It’s false to think that we do.

And some might say, well, what exactly was it was that you thought nurses do?

I dunno. Take care of sick people?

Well, yes, they do (we do, I do) but you still need an order for just about everything you do. In critical care a lot of your day is taken up with collecting data and then making the physician aware of this data, or else weeding out what the physician does and does not need to know.

Kind of like a secretary.

And then you write a bunch of notes. “K=3.2. Dr. Welby made aware. 40 of K given per the protocol, will recheck in 2 hrs.” (duh) or “Pt’s blood pressure in the toilet. Dr. Killjoy made aware and at bedside.”

or, “Pt is continually weeping and states, ‘I want to go home. I’m going to die.’ Dr. Beedlemeyer made aware. No interventions ordered at this time. Will continue to monitor.”

But every once in awhile I’ll have a conversation with a patient or a family member and get a feeling that I have really helped them and then I’ll remember, “Oh yes. This is what nurses do.”

Meanwhile I’m looking into nursing jobs that involve less orders and more conversations, because I think that’s what I am good at.

Hence the psych interview today. Hospice interview (hopefully) next week.