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Friday, November 9, 2007

A case against NT suctioning (agree or disagree)

RT Cave Rule #1: NT suctioning is a very traumatic procedure to be done only when excessive secretions are disrupting a >patients breathing and all other options have been exhausted.

"How would you like it if I took this suction catheter here, stuffed it down your nose and made you gag with it?" That's what I wanted to tell a nurse last night, but I held my tongue.

I like working nights, but there are some nights, like last night, where it would be nice to have someone here to back me up. In fact, if I had someone to tell me that I was right, or that I was being ridiculous, then I could have avoided the whole confrontation.

I was initially called at 8 p.m. to NT suction a patient who was in obvious respiratory distress. She had recently been moved from a recliner back to bed and her heart rate skyrocketed up to 177. Two days ago she had an abdominal surgery and now she was refusing to cough, and had some audible crud in her throat.

"I can't suction this patient," I said to the nurse. The nurse's name was Cindy.

"Well, we need to."

"I think I can fix her without NT suctioning," I said, and with a size 10 catheter I tickled the back of her throat and the patient spontaneously coughed producing a lot of phlegm, which I proceeded to suck up with the yankaur. Her sats increased, her work-of-breathing improved over the next 10 minutes, and, by the time I left the room, the patient was resting comfortably with a normal heart rate.

An hour later I was paged back to the room. "The patient won't swallow," Cindy said, "I have to give her oral medication for her thrush and she won't swallow. We need to NT suction her."

I said, "Look, I would be more than happy to suction her if I thought it was indicated, but suctioning isn't going to help the patient swallow. "

"Well, I put water in her mouth and she gurgles and spits it out. We need to NT suction her. She has a bunch of secretions in the back of her throat that she can't bring up."

"Not only that, but she has a sensitive heart. You have to remember NT suctioning is very invasive and traumatic."

"But we have that under control right now. Can we just try it once?"

I explained the procedure to the patient and she exclaimed, "No way!"

I looked at Cindy, "She's in no distress, has no audible upper airway secretions, and has no loud rhonchi. Let's just leave her alone."

"Well, we need to do something," Cindy said kindly. "We have to get this medicine down her throat, there's thrush all the way down there."

I encouraged the nurse to assist the patient with a drink of water which caused the patient to produce phlegm and gurgle. I simply sucked the junk up.

"There," I said, "Now you can give her her medicine." Cindy did and the patient took it just fine -- and we did not NT suction.

By this time I thought I had made headway with Cindy, but Cindy continued to call me back to the room several times during the night, and each time the patient denied any distress, denied she had secretions in her lungs, and I explained cordially to the RN that suctioning was not indicated. I even went out of my way to check on the patient every hour on the hour to assess her. Suctioning was never indicated, not even oral suctioning.

This whole thing really didn't bother too much, as I really enjoy working with nurses and educating them as appropriate. But, in this case, I felt I wasn't getting anywhere. I felt like I was trying to communicate with a brick wall.

"Look," I finally said, "You have a right to over rule me. If you want to suction this patient, I will be more than happy to assist you."

"No," she said, "I won't do that." Great, I finally got to her.

Wrong.

I was called back at 4:00 in the morning. By this time I'm exhausted and have a headache. I approach the nurse as professionally as I did each of the other times during the night and explain for the umpteenth time why NT suction is not indicated.

"I'm concerned about this patient," Cindy said. I think the patient deserves close watching, but I think she is fine right now.

"Look," I said. "The patient is watching a good movie right now. I'll sit in here and watch it so I can keep an eye on her." And I did. The movie was good too. This was one of my regular patients, and she really enjoyed me keeping her company.

Anyway, after the movie was over, I left the room and saw my boss thumping down the hall. "What's going on with this patient," she said.

Shit! I thought, as a rush of adrenaline flowed through my veins. Up to this point I didn't think there was a problem whatsoever, nothing worth getting my supervisor involved anyway. "How did you know about this patient?" I had a good idea, just wanted to hear it.

"Alex came to me." Alex is the nursing supervisor. "The RN complained the you were refusing to suction a patient. She thought that you were being lazy."

"Is checking on a patient every hour all night being lazy." I pointed at the patient. "Look at that patient. Does she look like she needs to be suctioned? If they'd just leave her alone she's be just fine, but they've been in there bugging her all night."

"I agree with you," my boss said. "I told Alex that you are a professional with a lot of experience, and if you thought suctioning was indicated you would do it. I had this same problem yesterday with Dave. He refused to suction a patient last night. Deja vu." She smiled.

"Well," I said, "I've been more than patient and professional with Cindy. And she seemed like she was really nice about the whole thing, but she didn't seem to be understanding what I said to her. But I certainly didn't think she would complain about me.

"Well, she did."

"I told Cindy very clearly that it was perfectly fine if she didn't agree with me, that she could suction if she wanted. Nurses can suction too."

"I told Alex that I backed you, like I backed Dave last night."

Certainly is nice to have the support of your boss. Damn nice.

Then, to be diplomatic, I said, "I could be wrong, Boss. I mean, when do you think suctioning is indicated? I mean, I think suctioning is very traumatic, so when would you determine to do it."

She said, "When a patient is full of secretions, gurgling, and the secretions are effecting her breathing."

"Okay, then we're on the same page."

We started down the hall toward the cave when the patient's doctor breezed around the corner.

"Hold on a minute," I said as I turned around. "I'm not letting this linger this time. I'm ending this once and for all."

I rushed to the nurses station where Dr. Matt was shuffling through the patient's chart. "Dr. Matt," I said, "May I have a quick word with you."

"Yes."

"Would you recommend that we NT suction this patient."

He looked at me like I was an idiot. "Absolutely not! It's all in her throat. If we could just get her to cough I think she'd be just fine. You can use a yankaur if you want, but I definitely wouldn't deep suction her."

"Thank you."

I turned around and saw that Cindy was standing right behind me, and a rush of joy flowed through my veins. I couldn't help but to smile. I said nothing and walked away.

2 comments:

jesus_of_suburbia said...

The funny thing is that had you complied with the nurse, and the patient went into an arrhythmia, she most likely would have thrown your ass under the bus.

just respiratory

Terry at Counting Sheep said...

How great to have a supportive boss, and you really took the high road with Cindy. You should get an award just for not losing your cool!

And when did nurses abdicate their responsibility to suction their patients, NT or otherwise? Shame on them.

Love your writing style - very nice reading.