I work in a teaching facility and thus hate July. Why? New Residents. They come in with high expectations, flashing the white coat like a badge and think they will fix everyone, be loved by all the staff and generally kick ass.
The reality is a little different.
I know they mean well. For too long they were cloistered in the halls of academia and they had some exposures to Real Medicine©, now it’s for real. The nurses put up with the inane orders like “bladder ultrasound per nursing qshift, straight cath for >300ml” in a patient with no history or issues with urination, with a chuckle and a knowing glance. We can tell when they get in-serviced on a new test/disease/condition/medication because all of a sudden they order it for every patient. You can tell when they get the C.Diff lecture as all of a sudden everyone who has a trickle of diarrhea is a “rule-out C.Diff“, even when said diarrhea is caused by stacked doses of Miralax, colace, senna, milk of mag and a Theravac enema since they haven’t pooped in 5 days. But it is when they come face-to-face with what nursing deals with 24-7 and their eyes go wide and they ask, “Really? You guys do this?” it is almost priceless. Case from last week is brilliant in it’s “Welcome to Medicine” slap-in-the-face reality check.
At midnight the patient was alert, oriented and cooperative and now at 4am they are claiming we’ve taken them from the hospital as they pissed all over the floor and nearly ripped out the IV line. We can’t even talk to them as every time one of us walks in the room they yell “Get the Hell out of here!” and refuse any intervention or attempt at re-orientation. Hard to re-adjust someone when they won’t even let you be in the room. So we call the intern. “I’ll be up to see them in a couple of minutes.”
When she goes in to talk with the patient, she pretty much gets the same treatment. Maybe a little nicer and at least they are willing to answer her questions. But pretty much it boils down to “get the Hell out!”
“I have to talk to my senior, but I think I’m going to give her something to calm her down.” she announces.
“I think that’s a great idea.” says the nurse.
After a conversation with her senior she says, “How fast can you get Haldol?
“It’s not on over-ride, but pharmacy is pretty good at getting it in for us, they know we don’t order it unless we need it.” the nurse replies.
“So I’m going to give her 0.5mg…do you think IM or IV?”
“Y’know,” says the nurse, “I’m not sure I want to be around someone who doesn’t want me there with a sharps, not really into running the risk of getting stuck.’
“Oh yeah, I didn’t think of that.” says the resident.
As she fills in her senior who has just come up I look over at the nurse, “0.5? Really? Maybe we should just wave the vial under her nose for all the good it will do, right?”
“I didn’t want to question her like that though,” said the nurse, “Don’t think she would really take it as the constructive criticism that it is…” She then goes off to pull the Haldol from Pyxis.
The patient is staying in their room, but refusing everything and is sitting there with a slightly pissed off expression, but you get that gnawing feeling in the pit of your stomach looking at them, that at any moment they might explode and take a couple of us with. It’s the calm before the storm feeling where you make sure there is nothing between you and the door.
So the nurse comes back with the Haldol and the resident asks, “So if she won’t let you even in the room, how are you going to give it to her?
“Unfortunately, we’re going to have to hold them so we can.” the nurse replied.
“Like hold them down?” slightly incredulous resident.
“Yeah, sometimes we have to do things patients don’t like for their own good. It’s not the best thing, but sometimes we have to.”
“OK. Can I come in with you, y’know, help?” she says.
“Sure, the more the better.”
They head to the room, three of them, the senior and I stand just outside the room in case we’re needed. “We have to give you some medication,” says the nurse “Go ahead and hold the arm,” softly she says to the resident. The resident lightly places her hands on the forearm.
“No, you’ll need to hold a little tighter, especially if she comes up swinging, I’ll dodge but you might be so lucky.”
Arm down, the patient is screaming a blue streak at them, “Get the fuck out! Leave me alone you fuckers!” but they get the med in and step out.
“Thanks,” the resident says, “I’ve never had to do that before…don’t always realize what you guys have to do. Now we need to figure why they’re acting this way,” she finishes as they walk off the floor.
And the 0.5mg? Didn’t do a damn thing. At least the resident got a little eye-opener out of it.
Disclaimer…we don’t randomly go giving anti-psychotics to everyone, there’s a bunch of important relevant details left out, but you get the gist of it.
Lost on the Floor 