Abdominal pain & nausea = a burger and coke?

Seems like that sentence is backwards right? It should be “a burger & coke = abdominal pain.” Except last shift it wasn’t. Patient with long standing abdominal pain & nausea of unclear etiology (read: there’s no organic or radiological evidence to suggest a reason for the abdominal pain) with multiple ER and hospital admissions for IV pain control and GI rest. So we throw the bus at her: nasogastric tube for GI decompression/rest (refused), nothing by mouth (complained), IV Dilaudid for pain (Yay!), encouraged mobility, because believe it or not, your gut likes you to walk (refused). Flash forward three days when she finally wakes up out of her stupor when docs decrease her narc dose and lengthen the amount of time in between doses (irate!) and liberalize her food options (your food sucks!). This is generally how these stories play out. And yet I surprise myself because I still get surprised when the first thing they order after DAYS and DAYS OF PAIN AND NAUSEA is a cheeseburger and coke. Two cokes and “put this one in the fridge!”

It’s like a hip replacement wanting to do yoga or a triple bypass itching for some cross fit the day after surgery. Doesn’t happen like that. So if this sounds like you…at least try and fake it, for my sake. Order some jell-o first.

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Allergies

You can tell a lot about a person by their allergies.  And I don’t mean the seasonal variety.

I don’t judge if you’re allergic to cats or dust or pollen.  I do, however, judge you if you’re allergic to morphine, oxycodone, ibuprofen, tylenol, Zofran, Reglan, Compazine, repositioning and hot packs.  Because, awe shucks, looks like the only thing left that you can possibly tolerate for pain and nausea management are dilaudid and phenergan.  At the same time.  While you’re eating a hamburger from food service that you’ve complained about but are still eating.  And it just so happens that those are the two most potent, euphoria inducing pain and nausea medications that we give.  Funny that.  (I just said that in a British accent)

There are some patients that think either their nurse is dumb or their acting skills are so stellar that I won’t see through their Oscar worthy attempt to get high.  I once had a 23 year old male that came in with a small bowel obstruction.  Not the most painful malady, especially after a decompressing NG tube placement, but certainly no walk in the park with your dachshund.  He just so happened to be allergic to every possible pain medication except Dilaudid, which is about 10x stronger than morphine.  So that being our only option I acquiesce to his request for pain medication.  As I’m drawing it up (with him twice verifying the dosage) to administer through his central line (his veins being rubbish after using them for other recreational purposes) he first requests that I not dilute it in saline (denied) and then as I’m administering it he performs a song and dance about how bad it tastes and if I could just “push it in faster” so the unpleasantness goes away quickly (denied).  Anthony Hopkins in the house folks! Somebody go get the golden statue! Little did he know he had just purchased his ticket to a slooooooow, American Society of Medication Safety by the book practice recommended 5 minute administration for every single dose there on out from this nurse.  I didn’t think I looked that dumb.  I am blonde though….

Another thing with allergies…you only know you’re allergic to something if you’ve received and had a reaction to it.  I hate when I’m researching a patient at the start of my shift and the first two things on their allergy list are Haldol and risperidone.  Shit.  That means that they’ve A) been in the hospital a few too many times and B) have needed an anti psychotic more than once, and C) what the hell’s left for me to give if I need it?!?

Deserve?

Deserve.  It’s an interesting word.  1: to merit, be qualified for, or have a claim to (reward,assistance, punishment, etc.) because of actions, qualities,or situation: From  Latin dēservīre –  to devote oneself to the service of, equivalent to dē- de-  + servīre  to serve.  Who decides who deserves what? God? Humans?  We clearly think we have that privilege (our justice system, capital punishment, welfare etc.)  Who deserves to live or die? Or rather, who deserves to receive treatment that will allow them to continue living?

I struggle with this question on a daily basis.  I admit.  I do.  Nurses are taught (or generally have the limitless capacity) to care.  The field attracts caring people.  How could it not? Why would someone who doesn’t care ever in their right mind choose this field?  They wouldn’t.  But believe it or not, there are times I have to force myself NOT to care.  Take today for example.  Today I have a good assignment.  Incredibly busy and hectic but filled with pleasant, positive, wonderful patients dealing with their illnesses the best way they can.  I’m feeling good about the kind of care I’m providing, a little guilty about how pleasant everyone is (that guilt is another post in itself).  And then I get an admit.  The diagnosis is
“gluteal infection s/p complicated I&D”.  I quickly scan the history and physical and find that this patient has been admitted exactly fourteen times in the past year for the same problem each time.  Surgeons have to go in and open and scrape out the infection that collects in his butt muscle.  The cause? Skin popping heroin.  After years of heroin injection he has lost the ability to inject directly into his veins and so has resorted to sticking the needle directly in his ass muscle.  And despite all the close calls, the brushes with death from sepsis, his behavior continues.  And each time he comes into the hospital, his life is saved.  His entire hospital stay is what we call “uncompensated care” which means he can’t afford to pay for any his healthcare and he doesn’t have insurance.  And he sure as hell isn’t getting a bill because he doesn’t have a mailbox.  And waaaaay downstream you and I, Mr. and Mrs. Taxpayer, get stuck with the bill one way or another.  Our premiums raise, the cost of healthcare delivery increases, our taxes increase etc.  Use your imagination as to exactly how the cash will come out of your pocket.

With each hospitalization this patient is provided with the opportunity to enter substance treatment (free of charge or course) and each time he declines, no doubt laced with a few profanities.  He is told frankly that his behavior is the cause of his infections.  He treats the staff like shit, orders copious amounts of food from the dietary department, insists on someone wheeling him off the floor to go outside to smoke, requests pain medication on the hour and undoubtedly that infection requires the most expensive type of antibiotic known to man (or GlaxoSmithKline).   He is not unique, unfortunately, he is a dime a dozen.  And I have a decision to make.  Do I care?  Do I waste my energy being angry at this person’s personal decisions? Or do I look at him simply as a body that needs fixing at this moment in time.  Does it matter the sort of decisions that land a person in their current situational crisis?  Does it?  WWJD?

Does this person “deserve” to continue to receive expensive life saving treatment when it is clear he will continue to participate in the behavior that got him to this place each time to begin with?  Should there be, like, a three strikes rule?  I hate that I don’t have an answer.  Some days I’m to tired to care.  Other days I care a lot.  I walk between patient rooms, moving from this patient to the 35 year old man with testicular cancer and two young children who color in coloring books quietly while sitting on the foot of his hospital bed, blissfully unaware that their daddy will be dead in a month.

Should I see these two men the same?  Both imperfect human beings who innately deserve the ultimate gift…life.