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Deadman, Chapter 8

Chapter 8

In the unit, you can only be assigned two patients at a time. This is a legal thing, a thing that most states audit hospitals for randomly to make sure happens. In a lawsuit, hospitals are without protection if it can be shown that the nurse was caring for more than two patients while working in an intensive care unit. This concept’s written fairly deep into medical stone, and although sometimes it’s pushed, it’s a rule that’s rarely violated outright.
Hospitals also charge more for the privilege of being in a unit, so it wouldn’t be ethically fair to scrimp on the help, though this wouldn’t stop the management from doing it if it were not for the legal thing. Management is not your friend.
 I think that hospitals find this somewhat arbitrary, so they make sure that nurses in the unit always get two very sick patients to care for at all times. If an assigned patient in the unit shows improvement- he or she is transferred to a “step down” unit- where an assigned nurse can be given 5-6 patients. Unit nurses float down to these units on slow days, and we all hate it – it’s too confusing and very scary.
I also think that hospitals are a bit upset that they now have to pay nurses, with money, to do the things that nuns used to do for free -- as part of their marriage contract with the lord.
As a nurse, you get the money, but never any other perk -- No lunch brought to you on a busy day, no Christmas bonus for saving people like Jesus did, no educational reimbursement for classes that make you better at your job – None of these things – just the money, and the money is pinched out to you resentfully – you get the feeling that they would pay you in stamps if they could get away with it. It’s not the tightness of frugality – it’s the tightness of resentment.
(I will only say this once, and will probably cut it in later versions  – men would not put up with it – it’s that kind of thing.)
There is a saying that, “God wont give you more than you can handle”, but it’s also true that he wont give you much less either. If you don’t think things through, plan your time carefully, and act appropriately, things will get away from you in a Coronary Care unit.
From my other patient’s room, I saw the call light blink and bonk from above the door of Posey’s room. I poked my head around the corner and  into his room, and told him I’d be right in. I finished up changing a dressing on my other patient, taped it up well, and headed over to see what I could do for Posey.
 He had woken from his nap diaphoretic (sweaty) and slightly short of breath. He asked for my help getting up and over to the side of the bed –he hadn’t urinated all day, and said that he couldn’t do it from the position he was in. Dangling from the bedside with my help, he held a urine collector (a plastic, wide mouthed jug) with one hand, staring into space as he fumbled to put his penis into the bottle. Nothing happened for a while but a slow waiting, and after a while of this, I got impatient.
 Since Dr. Q had left an order for a Foley (urinary catheterization) if needed, I tried to scare the pee out of him. I explained the procedure for inserting a Foley -- the latex tube that I would need to place up his penis, the length the tube had to travel before it got to his bladder, and, with my fingers to demonstrate, the width of catheter.
 I have found that describing the procedure usually keeps me from having to perform it, it kind of weeds out the fence sitters.
I supported Mr. Posey and helped him stand by the bedside to urinate. I was starting to think that the urine thing was not willful misconduct on his part, and that maybe he couldn’t pee because he didn’t have any pee to pee. I helped him back to bed, and headed of to the storeroom to get a catheter kit. Fear can powerful motivator, but sometimes you have to prime the pump with a little action.
When the heart is pumping poorly, the pressure in the system gets lower – this is blood pressure, the same thing you measure in a Walgreen’s while passing away the hours waiting for your prescription to get filled.
The kidneys work like a mesh filter that’s made of meat—and blood pressure is what pushes the blood through the filter, leaving wastewater as a result, to be collected in the bladder and later eliminated as urine. With low blood pressure, less blood get filter through the mesh and less urine is collected and eliminated. With less fluid eliminated by the action of the kidneys, the more the body holds on to the fluid. As I have noted earlier, more fluid makes the pump work harder.
This would be fine if it were just an isolated action of a single organ. Many people their lives comfortably as juicy fat guys that their kids bring out at Christmas as a prop to hand out presents. But there’s more.
 The body adds to this problem by reflexively sensing the poor pump function and releasing a hormone that causes the body to hold on to its fluid. It’s the same reaction that follows any major trauma or blood loss, but is harmful when responding to heart muscle damage. The body is saying, “ I don’t know exactly what’s going on around here, but it’s really bad and I think I’ll just hold on to everything the way it is for awhile”.
It might explain how FDR got elected four times; it’s the same concept.
When you have surgery- even something as simple as a hernia repair- in the first 24 hours after surgery you gain water weight, and in the next 24 hours you pee it all off. It’s how the body reacts to what its sees as damage.
 After a heart attack, one of the best ways to see how the heart is holding up, is to measure the urine output of the patient. A surgeon once told me, if the patient’s feet were warm, and he was making urine, nothing too bad could be going on inside.
The minimum urine output is around 30cc’s every hour (a coke can is 325cc’s,) any less than that and the kidneys start to fail.
In Mr. Posey’s case, I had decided to go ahead and place a catheter in bladder to allow me to measure his urine output better. Back from the stockroom, I opened the kit and spread it out between his legs and uncovered him.
 The Foley catheter is about half the diameter of a #2 pencil. It’s made of latex and is yellow in color. After putting on sterile gloves, I held his penis in my left hand and pulled down his foreskin with my right. I cleaned the area well with an iodine type solution (povidine,) and then lubricated the tip of the catheter with a water-soluble gel. I both pushed and slid the catheter into the hole of his penis (urethral meateus) and ran it up about 8 inches, until I say darkly ambered urine slowly flowing into the drainage bag through the clear drainage tube. Knowing that the catheter was now in the bladder, I inflated a small balloon with sterile water to keep the catheter from falling out.
Mr. Posey had flinched when I first started the catheter, but then, so did I. I remember when President Clinton told that group of flood victims that he felt their pain—this is the same pain that I felt. I have never had a catheter placed in my bladder and could only acknowledge that it probably hurt. I felt sympathy, not empathy –  sorry for, not sorry with.
I hung the bag on the side of the bed when I finished. Less than 300cc’s of dark urine came initially from Mr. Posey’s bladder. The color indicated that it was concentrated, sort of like when a young person gets the flu and doesn’t eat or drink for a few days.
I looked at it and planned to measure the urine output closely for the next few hours to see if the lasix and digoxin I had given him earlier were working. If they were, I would expect to see a gradual increase in the amount of urine coming out, and a lighter color as the urine became less concentrated. If they were not, we’d go on to the next thing.


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