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Monday, July 21, 2008

You absolutely do not want to be suctioned

As I was reviewing my patients chart at around 10 p.m. last night, a saw an order that I as not informed about in report. The order was this: "RT to NT suction patient Q4-6 hours with breathing treatments."

I just about flipped. You can bet that I cursed. I couldn't help it, this may simply be one of the stupidest (is that a word?), doctor orders in the history of my life.

It was about as stupid as when i was a patient last October, and this very same doctor ordered a foley catheter for me -- of which I so duly refused. I certainly didn't need a tube stuck into my privates when I was fully capable of going to the bathroom on my own.

Thank you, but no thanks.

I looked further, and the doctor wanted the NT suctioning to be done in order to get a sputum sample. I have to tell you something dear readers, and this brings me back to my very first RT Cave Rule:

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

Now, allow me to tell you about this patient. He was a 29-year-old man who came to the hospital seven days ago because he had been suffering with very bad side pain for about three days. The general surgeon ended up having to do a laparastoc surgery on him to remove his appendix.

On his second day after the surgery an RRT was called on him because his SpO2 dropped into the 70s. He had developed some atelectasis and maybe even pneumonia due to his not taking deep enough breaths for all this time he has been hurting.

But, in the past two days we had weaned his Oxygen down from 100% to 4LPm. He was obviously getting better. So, now, why the hell would a doctor want a sputum sooooooo bad that he has to order this invasive procedure? I'm telling you, this procedure is really terrible.

"We need to suction this patient after the next treatment, Rick," the patient's nurse said. She was a relatively new nurse, and was quite laconic.

I was blunt: "Absolutely not. There is no damn reason this patient needs to be suctioned."

"Well, it was ordered, and if you're not going to do it than I'm going to."

"How would you like it if I poked a tube into your nose and sucked the air out of you while you were completely awake, and do this very traumatic procedure for no flipping reason at all."

"The doctor needs a sputum sample. And the patient isn't spitting anything up."

"The patient has been here for four days, and has been on antibiotics all that time. What good is a sputum going to do now. It's an absolutely stupid procedure." Besides, the doctor doesn't NEED this sputum, he WANTS it. "Would you want someone sticking a tube up your nose?"

I looked at the other nurses: help anyone???

"Absolutely not," one of the other nurses put a finger in her throat and feigned a gag. "No way would someone stick that down me. That's absolutely inhumane." Ah, right on cue.

"It is inhumane," I said. I looked at the melodramatic nurse, a nurse I knew had excellent common sense and I knew she would agree with me on finding a way not to suction just because an order was written, and then at the attending nurse.

"Well, we really need to do it," the attending nurse said.

"Awwww, I would never..,." the melodramatic nurse made a noise like a disgusted cow, "No way. I.... whooooo.... I would never want THAT done to me. NOOOOOO Wayyyyyyy."

I was hoping this melodramatic display would convince her coworker here that this was one doctor order that should be skipped, but in a professional way of course.

"Well, we still need to do it."

I said no more. I knew a losing battle when I saw it. Besides, I had a great working relationship with all these nurses, and I didn't want to insight flames. There's more than one way to skin a cat, and I'll figure something out here.

Now I had to do some damage control.

"Sorry, I didn't mean to get you mad at me," I said to the attending nurse, " I just think this is an asinine order." Plus I'm extremely tired, and have lost my ability to be diplomatic.

"That's okay. You don't have me upset. I understand your point-of-view. I'll just do it myself."

Now she had me feeling guilty.

I did a review of the chart, and learned that my co-worker on day shift yesterday, the same one who had, I thought, conveniently forgotten to tell me about this order, had attempted the NT
suctioning of this patient immediately after the initial order was written.

Joy rushed up my veins as I read her charting.

"I see here that my co-worker had already attempted to do this yesterday," I said, "And all she got was a little blood." Figures, thought, because the blood was probably from scraping the back of his nose with the catheter.

"Well, still, I'm just going to have to try for it after your next treatment. That's okay, just let me know when you do your next treatment."

Ahhh, you're about as obstinate as myself. Okay, you win. I will find a way to get a sputum out of this man one way or another.

I woke the guy up from a sound sleep. "Oh, please, do you have to do this now," he grumbled.

"No," I said.

He went back to sleep.

"He refused," I said to the nurse.

"Okay," she said. Wow, that was easy.

But, the responsible thing to do was to try again.

Two hours later.

"It's time for your treatment. We have to do it this time." Whether you need it for those crackles or not.

"Oh, okay," he grumbled.

"After this treatment," of which you do not need either, "I'm going to to have to suction you like that lady did yesterday."

"What's that?" His eyes became big.

"That tube in your nose."

"How often?" He was looking me square in the eyes. Looking in those things, I could read his thoughts.

"Every four hours. That's what the doctor wants."

Why don't you simply refuse? Please just refuse. I don't want to do this to you, and you don't want me to do it to you. Please just refuse.

I watched him as he did his treatment. I could see he was deep in thought.

"Okay, we're finished, why don't you roll over so I can listen to you," I said, after I snatched the nebulizer from his, rolled up the O2 tubing and stuffed it into the plastic bag.

He painfully rolled. He took in a deep breath. He produced a mouthful.

"Don't spit."

"Oh, I most certainly will not," he mumbled through closed lips, making sure not to swallow.

I placed the cup by his mouth, and he let the thick yellow and blood tinged sputum slide into the cup. I closed the lid.

"I got your sputum," I said to the attending nurse as I left the room. " I scared the S#$# out of him, and he responded. Works every time."

She gave a faint smile, "Awesome."

RT Cave #29: If the doctor orders for a patient to be NT suctioned because the patient cannot obtain a sputum sample on his or her own, explain the procedure, make it sound as miserable as it really is, and wait for that sputum to find its way into the cup.


Heidi said...

Yep, that sounds about right. Just scare the ever lovin sh*t out of them with pain, burning and scraping of the inner nostral....they'll cough it up every time!

Amy said...

You know what? I'm passing this along to everyone I know. I've never been hospitalized except for pregnancies and therefore never faced the procedure, but who knows what the future holds? I'm very glad you wrote this--thanks!