Thursday, April 29, 2010

I am really uneasy with the decision my boss made for a patient today..
1- Because there have been scant medical investigations done prior to diagnosis.
2- Because the patients behaviour was unconductive to more invasive investigation.
3- Because the decision- I feel- has been pushed by nursing staff.
My boss was bullied!!

The scenario was this:
Patient with locally invasive bladder cancer comes in with difficult to control pain. We titrate her pain medication up with morphine. The pain seems to be from her back. We query whether it's due to spinal cord invasion due to her cancer. We get an MRI and that's normal. Meanwhile we start ketamine.
She gets acutely confused, delirious, and aggressive- throwing chairs at staff for example.
We think maybe this confusion might be her drugs- so we wean down her pain relief and stop the ketamine.
Still not better.
We think infection, but no sources found anywhere and she hasn't been feverish.
Meanwhile nursing staff are asking for midazolam to sedate her.
A few days pass. Still no answers for her difficult to manage aggression and confusion.
The nurse manager asks us for a continual infusion of midazolam in order to save money getting a one-on-one nurse for the patient to prevent her from harming herself.
We say we would like to investigate the reason behind her delirium instead of drugging her!
And also there's a known 'paradoxical' effect with benzodiazepines which might provoke aggitation..
The following day, the nurse manager again asks for a continuous infusion of m's idazolam.
It was then that my boss came up with a diagnosis- encephalitis caused by a paraneoplastic syndrome from her cancer.
Conveniently there is no cure- it only gets worse and she is started on a midazolam infusion.

People might think that doctors run the show in hospitals, but like the tooth fairy, it's all a convenient myth.
The real ones in power are nursing staff. And sometimes that's a good thing- when good nurses are around and have sound clinical knowledge coupled with great knowledge of the patient. Sometimes it's bad due to the opposite.
A lot of this isn't particularly interesting, but it's the first time i've actually doubted my bosses decisions! Hmm

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