Dr. Q disappeared on me before I could talk to him again, but I knew he wouldn’t leave without writing new orders. I glanced around and saw Posey’s medical record next to me, open and obvious, and filled with Dr. Q’s new orders. They were written neatly in the crisp blue ink of a Mont Blanc fountain pen. I had no idea how he got the chart there without me seeing him do it, but then, true magic is only a surprise when you choose to see it. My morning was too busy to get excited by a silly parlor trick, and I’d seen this one too many times to give it much more than a thought.
I picked up the orders and reviewed them. I stamped up lab slips to be picked up by a runner, tore off a copy of the orders and arranged for it to get to the pharmacy, filled out a med sheet to be used for documentation, and then transcribed everything on to a Kardex -- to be left at the bedside in Mr. Posey’s room.
On admission to the unit, patients came to us with standard orders – three sheets of pre-printed instructions, each page loaded with check off boxes, and long narratives, of what could, or could not, be done when the patient arrived to the unit. I actual fact, they were mostly boxes the ER doctor casually bubbled in before the patient came up, and a formality to be signed off later by the unit doctor.
These general orders covered almost any emergency, and they were reviewed and updated by a hospital committee yearly (– ah, to be a fly on the wall for that meeting – what dreams I would have as I slept!) These orders functioned as the due diligence part of a legal requirement, and were intended for use until the unit physician could show up and do his own evaluation. In practice, and this was key, they remained in effect for the entire time the patient stayed in the unit. Since time was not a friend of the western, more interventional practice of medicine – things that needed to get done, needed to get done quickly – and having orders that covered almost everything -- also covered almost anything. For doctors, standard orders were the trade off they made in order to go home at night -- for nurses, they were the keys to the kingdom – the kingdom of autonomy
This was why the unit was the best place to work for a certain type of nurse, the autonomy. As long as you had good reasons for doing the things you did, you were not only covered for anything that might come up, you were required to do what you thought needed doing. Standard orders were left vague on purpose; they were guidelines, not rules. This was the cowboy part of the job – running wild in the free range of possibilities, herding a few choices towards something that might make a little difference. And you didn’t have to ask first, and then sit around to wait for the answers.
Dr. Q left new orders that looked like this:
- Clear liq, adv as tol.
- OOB with assist only
- O2 N/C, titrate, keep sats >92%
- Lasix, 40mg. IV now, and Q6 hrs.
- Digoxin 0.50 mg. now, then 0.25mg Q6 hrs X 4. Hold for HR<60
- Ntg gtt. – titrate – keep sys Bp > 100, <140.
- MSO4, 2-5mg. IV, prn pain – call if not relieved after 2X
- Heparin 5,000mg SQ q12 hrs.
- CPK Q8 hrs. X3,
- daily - Port CXR, CBC, Chem 20, EKG, Pt. PTT.
- Schedule 2D-mode Eco ASAP
- Foley prn. Call if U/O < 150c/4 hrs.
After carefully checking each order off with my ballpoint pen as I finished them, I pulled a yellow tag on the outside of the record, to leave a request for another nurse to check my work when they got a chance. I pushed myself away from the counter and walked down the hall to the satellite pharmacy to pick up Posey’s meds. I signed out a couple of the medicines we had in stock there, and asked for the others to be sent up when available. I picked up a carton of apple juice from the lounge, and headed back to Posey’s room.
As I started to enter the room, I remembered how big Posey was, so I grabbed another nurse that was loitering in the halls to help me with a lift. Posey had collapsed to a hunch since I had last been in and was no longer bending in the middle the way god intended. I didn’t want him moving any more than necessary, so I lowered the bed and, as the other nurse I grabbed from each side the draw sheet, we yanked together after counting to three, and pulled, until Posey’s head bounced off the headboard. After apologizes, and a quick look for blood, the other nurse left, and I cranked the bed back up so he wouldn’t choke when he took his meds.
I gave him the two pills I’d picked up at the pharmacy: Digoxin to make his heart contract more forcefully, and Lasix to cut down on the volume of fluid that the heart had to pump.
Digoxin is also known as foxglove- and it’s been around forever, in one form or another. Digoxin does two things: it slows the heart down, and beefs up the hearts contractions. The good and the bad part about giving digoxin to a patient directly relate to -- what it does and why you give it. Digoxin makes a failing heart work better by chemically flogging it to put out more effort. As it makes the heart contract with more force, it also uses up more energy, energy that has to come from the heart muscle – which is damaged, and the reason why you are giving the digoxin in the first place. In the short run, when the immediate problem is fluid overload and maintaining blood pressure, it’s useful. In the medium run—making a damaged pump work harder in order to fix it is a bad thing. Just think about it for a minute.
Lasix is the drug that you give to a horse prior to a race, if you want to win, and you have no ethics—it allows a horse to run better by taking fluid out of their system. Lasix also makes people pee, like a racehorse, though the race is different and the ethics less of a compromise.
The more fluid you get out of the body by urinating, the less fluid the heart has to pump around the body. Less fluid—less work. If the pump is putting out 4 liters every minute, and you decrease the volume to 3 liters a minute- you get a noticeable improvement in function – it’s doing less work, and the work it is doing takes less effort. It’s the same principle that the old time barbers used when they bled their customers in the dark ages, after they used a hand held massage wand to loosen up their neck muscles and after spraying them with something that smelled almost pretty – Same principle, except without the red stuff gushing out.
I explained to Posey the pills I was giving him, and what I was giving them to him for, as he dry gulped them with a small sip of juice,. He seemed unimpressed with my knowledge, and asked if his wife could come in for a visit. I told him I’d look for her in the waiting room after I finished up. He denied having any pain, and seemed fairly comfortable. I listened to his chest, checked his feet again and walked out to look for his wife.
The waiting room was at the end of a short hall. No one was in it when I opened the door and looked around. I knocked on the attached restroom and got no answer. I went back and let Posey know that I couldn’t find his wife, but that I’d keep an eye out for her. We both assumed she was in the cafeteria eating lunch, but neither of us saw any reason to disturb her with a page.
Posey napped for a couple of hours. He continued to have his vital signs (blood pressure, heart rate and respiration’s) taken automatically by the preset monitor connected to his bedside. His heart rhythm was visible at the nurse’s station. He slept with the head of his bed elevated, and on his back. He napped in a fitful off and on sort of way. I spent most of my time in another room my other patient- a person I don’t remember anything about, but I’m sure was at least as sick as Mr. Posey.