Oh, The Agony of Ambition

Posted by Nicki Baker at Friday, September 09, 2011

Wound Staging...the pleasant cartoon version

(Hang in there, this is a long one...)

I have long been baffled by nurses as a species.  First, I can’t for the life of me understand how a single profession can draw in the most tender, loving individuals and at the same time attract the coarsest, unhappiest people.  What is it about nursing that draws these extremes of personality? 

Second, nursing seems to be one of the most demanding professions in existence, right?  Well, knowing this, what makes a person choose to become a nurse over, say, a physician?  Sure it’s a bit more school, but I can’t imagine it’s more difficult than nursing in the long run and it certainly pays more and garners more respect.  Nursing is an arduous, thankless profession and I’m incredibly grateful that there are people out there not only willing, but wanting to be a part of it. 

Anyway, my respect and admiration for nurses further expanded today after spending the longest half hour of my life with three of them on a wound care visit.  Many of the patients at Select have been bed-ridden for long periods of time, whether from paralysis, acute injury or long-term residence in a nursing facility.  This can cause extreme muscle atrophy, skin break-down and ulceration.  Wounds are one of the reasons that patients are brought to Select and the wound care they receive is outstanding.  A great learning opportunity for an eager student…

So I ran into one of the wound care nurses and asked if I could tag along to observe.  Well sure!  Perfect timing, in fact, the next patient had a good variety of wounds so I could see an assortment of stages and severities in one stop.  Perfect! 

I couldn’t believe what this poor man’s legs looked like when the covers were pulled back.  He is a big guy, probably 260lbs, but his legs were so underused and atrophied that his calves were nearly the thickness of my forearms.  They were purple and had sores on them and his heels were missing areas of skin.  The nurses explained the staging system for wounds and pointed out examples of each on the gentleman while he endured the painful processes of manipulation and wrapping.  By the time we arrived at stage IV (yup, that’s down to the bone) I was glad that I had skipped lunch.  There were also a couple of “unstageable” wounds, meaning there was too much necrotic tissue present to determine the depth of the injury.   I did my best to pay attention and participate by helping measure and photograph the wounds, but I was putting a lot of effort into not gagging or passing out. 

With his leg wrappings replaced, it was time to move north.  The nurses rolled him onto his side and removed the dressings from his bottom and low back.  The wound on his bottom was very clean, but it was difficult for me to bear.  It had been packed with medicated gauze, which, when removed, revealed a softball-sized pocket of absent tissue.  Trying to stay engaged (and conscious), I asked how long it would take a wound like his to heal and was told that if cared for properly, it would take months for the wound to heal and would require daily dressing changes.  If he plans to go home, his wife is in for a lot of work.  It’s hard to imagine anyone but a professional being able to stomach that process, but when I think about it, if it ever came to it, I’m sure I would do it for my boyfriend.  In fact, I guess I’d rather do it myself than have anyone else do it for him.    

The team was pleased with the condition of the wound on his bottom, so they repacked it and moved on to his lower back.  In my opinion, this was the most severe of the three.  It looked like a hole in his back and was about the size of my fist.  One of the nurses explained to me that skin that is pink or orangeish is what we want to see, while black, blue and yellow tissue means trouble.  I’m not sure if anything besides photographing and measuring was done to this wound because I gave in and blurred my eyes while they worked on this last one.  It’s a trick I used as a kid when I didn’t want to watch the scary parts of horror movies but wanted it to look like I was catching every gory scene.  I felt I’d gotten the gist at that point. 

It takes a unique person to be able to do what those nurses do.  They are incredibly tough – able to stomach any injury and determine its severity and what will best allow it to heal, then they perform any debridement and mechanical care needed.  I was simultaneously amazed and appalled.  Not only could I never handle the wound care itself, but the pain that you inflict in the process of cleaning and dressing the wounds is clearly intense.  I realize it’s ultimately what’s best for the patient, but I don’t think I would be able to continue a dressing change while the patient moans and wails in agony.   Again, my esteem, appreciation and bewilderment for nurses have grown. 

So, yes, this was a great learning experience for me and it’s probably a good thing that I didn’t hesitate before asking to tag along, but when I next find myself with spare time on my hands, I will certainly not be donning a gown, pulling on gloves and seeking out the wound care team. 

Live on the Verge of Death

Posted by Nicki Baker at Thursday, September 01, 2011

I’ve worked at Select Specialty in Ypsilanti a couple of times in the past when I filled in as a technician and I’m excited to be spending my second rotation there. Select is a long-term acute care facility located on the campus of St. Joseph Mercy Hospital and cares for patients with complex medical needs who require an extended hospital stay. Many of them are on ventilators, PEG tube feedings and IV antibiotics. They’re currently at capacity, caring for 36 patients.

I generally start the day by checking INRs for patients on warfarin. Select has a combination of electronic and paper charts, so I can get lab values from the computer but have to go to each patient’s room to check the MAR to be sure they were given the warfarin dose they were supposed to have received the previous evening. Based on the patient’s INR trends, I decide whether to continue them on their current dose or to make a change. Since I’ve been there about a week now, I’m starting to see the impact of the changes I’ve made. It’s really fun and gratifying to see patients become therapeutic or to be moving in the right direction based on decisions I’ve made. I’m also enjoying writing orders for warfarin and lab draws, which pharmacists at Select do per established protocols.

Antibiotic stewardship is another of pharmacy’s responsibilities at Select. Checking culture results and making sure all antibiotics have reasonable stop dates is part of the student’s job. I’m glad that I’m getting a chance to work with antibiotics a bit more since it’s an area I need to improve in.

Working with this population really makes you appreciate your health and the health of your loved ones. A lot of the patients are very old an ill, but some of them are younger and trying to recover from falls, accidents or infections. Many of them will improve and be transferred to a skilled nursing facility, inpatient rehab or even be discharged home, but for others, this will be their last stop. It’s difficult to see some of these people struggle, but even more difficult to watch their families make tough decisions. I guess what these patients are going through could best be described as living on the verge of death.

It appears difficult for physicians to let these patients go, even when it feels like the time has come. It seems to be against their nature, like they're admitting defeat. As healthcare professionals, we've devoted ourselves to preserving and extending life, so being ok with letting a patient pass away feels contrary to what we've been taught.

Still, the respiratory therapists, physicians and PAs, occupational therapists, nurses and pharmacists at Select take great care to do what’s best for patients and families. Some really amazing stories of recovery have come out of this place. A woman who nearly passed away from a terrible case of H1N1 stopped by to visit yesterday. It was obvious that she had a real connection with the staff who cared for her during her stay at Select and she was doing great.

This blog is becoming a blab. More later!