Bullies

[whitewriter]

Background:
DAY 6 post decompensated liver failure. Transferred from a private hospital. Not for transplant due to extreme deterioration. Key feature: Hepatopulmonary syndrome (which I don't remember having encountered in the last 3 yrs). Very interesting condition.

Other issues: half hearted palliation: on noradrenaline up to 15mls/hr single strength overnight (not a small amount) not for CPR not for intubation. Not for escalation of cares (but clearly the noradrenaline and the HFNP delivering 100% FiO2 is keeping this soon to be not here guy alive).

09:00
AM rounds
I'd had the pt all of 1.5 hours
Handing over to the neighbours I'm swapping with
ICU team is rounding. It's 2 juniors (should be a reg and an intern) + consultant.
I know the docs are new. One of the in-charges was complaining 2 weeks ago. I'm not there enough (2 shifts a week) to really know whose who and whats what (but the consultants stay year in and out so I know them all relatively well).

Pt is somewhat collapsing - he's been collapsing all night. Sp02 aim is >85% and we are on 80% FiO2 on high flow with 30 of flow. The night staff stated at a flow of 40, he just looked like he was struggling - and at 30 things appeared better.

Anyhow. He was a bit up and down on the Sp02 so I did the normal thing - **after consulting the instructions from the previous day which stated nurse the pt at 45 degrees** and seeing his bed was more like at 20 degrees - increased it to 35 degs (any higher and he looked like he might fall out.

I thought that might (but apparently not for hepatopulmonary syndrome) help his oxygenation.

Consultant starts yelling about how come it wasn't handed over that the patient was to be nursed supine and to remain supine. She tries to rat out who was the staff who handed over to me(it's all documented in the notes). She's almost yelling and wants to know why things aren't being handed over when she clearly informed 2 RNs that the pt is to be supine.

I immediately questioned (in my head) if I was reading the wrong instructions re: pt to be nursed at 45 degrees. I checked the notes while the juniors were examining the pt (and also once again, being yelled at by the consultant for a substandard physical examination (they'd missed the hippus because they hadn't shone a torch in the poor man's eyes long enough to see it)

-- I get that he's a super interesting case - but if your going to yell that this man's GCS is clearly higher than a 9-- it is and it isn't: like sure he obeyed one command: which was to poke out his tongue. and his improved verbal score was due to him saying "yes" when I had asked if he could drink the lactulose (before he promptly aspirated and desaturated). So... I'd say that was a very loose 14 (E4V4M5).

We aren't going to treat a drop in GCS and we aren't going to herald an improvement in GCS as a sign he's getting better. We are a teaching hospital so apparently we can't just let a poor man be.

Anyhow. Moving along. This is potentially one reason they ask family to leave during the morning rounds.

Mostly it's for the non-palliative patients where an accurate GCS will determine treatment - and an accurate GCS (and I'm reading up a little <ahref="https://litfl.com/glasgow-coma-scale-gcs/">here is apparently not really a thing -- can determine if a patient gets allocated to go to scan.... further treatment, yadda yadda. And it can be brutal. The consultant asked me if he was localising (before he then poked his tongue out to command)... and I went to touch his shoulder and the guy winced at me.

I couldn't bear to actually find out if he was localising. He feels pain. He's on a palliative pathway. I'm not cruel. He clearly had the presence of mind to anticipate what I was about to do.

--

I informed the consultant (this is my version of sticking up for myself) that she had written to nurse at 45 degrees yesterday morning. she counteracted that in the afternoon in another note it was stated to remain supine.

Honestly - I double checked - I couldn't find such note.

But by then the sting of the moment had gone. I was half appalled she was treating her juniors in such a way - and I just wanted to get back to the damn neighbor handover - which - as we were all seniors doing a 3 way swap - when I'd had to bow out of the handover - had then just proceeded to start swapping without me. Because you either go on time or you don't go at all.

We are great with breaks in ICU but it is rather timely -- especially if someone has a scan or a procedure at a certain time.

Anyways.

I did have a debrief with the other RN - who I'd like to mention is caucasian - who said that we really shouldn't have let the consultant walk all over us like that, because it's just not on.

And while in principal I agree with her- and I am glad that I did stand up for myself in stating that it was documented to nurse the pt at 45 degrees - (like if thats not what you want lady: delete it)--
It made me start to question what was going on in her life that was making her extra .... crazy today. Like she's not always a yelling consultant who goes around shredding people's dignity and sanity (questioning if they'd read the wrong notes) - it's partly personality (like I wasn't surprised she was doing it: and I've known her ever since she became a consultant and I was an incharge in neuro ICU -

we don't get hepatopulmonary syndrome in neuro.

And this comes back down to that whole thing that another senior RN was saying a few weeks back: patients in the wrong units (like say a stroke patient being in the general ward or a renal or liver patient being in neuro ICU) have a 60% increased risk of poor outcomes. Just simply being in the wrong unit - with staff who aren't fully understanding of the ins and outs of the treatments and methodology behind how we care for that type of condition. I know you'd think general is general - we should be jack of all trades - but even within general there's specificity. Eg. we don't get lung or heart transplant patients because we don't do lungs at MISH. We get liver or kidneys, but that's about it. Those go elsewhere to their actual specialty hospital (which is ~10km away approx).

I digress. So while the sting had well died down -- (also because the consultant looked a little guilty that the pt desaturated whilst I gave the oral lactulose that she had ordered due to her disgust that we were giving him rectal lactulose. Lady we were just disgusted that we were in a half palliative status with this guy- torturing him for bowels open to treat his encephalopathy when it had already been decided - that there is. no. treatment. option that will solve him. And that while I'd love for that lactulose to like, improve his alertness. Let's face it. It's probably not going to in a person with anywhere from 1 hour to 1 week max. to live).

So.

What do you not do with a patient as precarious as he was in terms of oxygenation?

You don't roll him. 'Cept he'd done a poop and was looking all uncomfortable. I send the family out - and we rolled, washed his bottom, changed the sheet, cleaned his mouth- put on some lip balm -

to have him desaturate to 50% Sp02. I turn up the FiO2 and the consultant looks busy so i inform the reg of his deterioration. He asks for an ABG. I ask why.

There is no treatment option for anything that comes up on that ABG and it's going to be a waste of $60. I didn't say it like that, I said - he's palliative.

He interrupts the consultant to let her know - and now we're on the right track, getting morphine/midazolam and glycopyrollate.

Not a second too soon - as the family comes in he's starting to look like he's really suffering in terms of breathing and etc.

He dies peacefully, a short death at the least. On a fair bit of morphine and midazolam but considering his respiratory distress as his rapid lung failure due to liver disease due to drinking 2 bottles of wine a day for xyz no. of years (doesn't seem like much, does it... but 1.5L of wine is a lot of alcohol per day) he needed the pain relief.

Part two

Junior RN states she's been asked to send off bloods for her pt. and also replace the potassium and magnesium - at the request of the Dr (the same reg who was being cajoled before)-- the electrolytes had already been replaced off the 0200 bloods by the nightstaff -but the pt was in AF and it wasn't abating. She'd been started on oral replacement and was wardable - I've seen very aggressive electrolyte replacement in cardiac ICU so I didn't question her too much, 'cept in regards to how much she was planning to give and why (the figures she suggested were based off the 0200 bloods, which in hindsight are clearly irrelevent considering, it had been replaced since - but since she said the Doc wanted it, (and what I'd seen in cardiac) I was like - yeah - sure- sounds reasonable, she's got a central line go ahead.

lolz. famous last words.

The consultant saw the replacement and lost her shit. Finds the new RN( the morning one not the PM one that had consulted me) and asks about the electrolytes. The new RN basically sqweaks the Dr had asked for it and the consultant is like "which one, point him out"

So the poor thing does.

and then the consultant lets loose on the Doc - about how the bloods are irrelevent. The patient is a ward patient, no one is going to check when the patient goes upstairs. That if he's not sure (he justified his position saying that the orals take time to work and he didn't think it would have been fast enough - although there were no new blood results to back up their requirement - like imagine they had renal issues on top ... anyhow) -- Now newbie nurse isn't going to question the reg. -- I think thats what let her off the hook from the consultant's warpath.

But still. They'd asked me - and I'm no newbie but also - that's not my pt. Although i had been reluctant to do more bloods and replacement, I'd defaulted to the "well if thats what the doc asked for"... lolz my mistake.

Then the Doc goes to fix something up or I don't know what - moves away from the group doing the rounds - and the consultant calls him back, saying he's not participating in the rounds, that he needs to get in there and blah blah. Poor guy can't get a break.

I started to think that maybe its more than just consultant with new doctors and that maybe it's cultural.

The consultant is Indian and so too is the reg. Would she be this way with a caucasian junior?

Have I ever seen a caucasian consultant act this way with their juniors? They've been passionate to be sure but not quite so direct in their almost blatant pointing out of mistakes.

The Reg appeared scared to approach the consultant. Not quite the relationship you want with a newbie around. What a nightmare.

I wanted to give the poor guy a chocolate or something. He's had enough being told.

How is this fostering some sort of environment that's meant to encourage people to speak up exactly?

If this is what she (the consultant) is like at work -- what she's like at home. She has children --
how does she treat them? Then I went down the rabbit hole of thinking, cultural parenting of being bullied by ones parents -

if she (the consultant) was parented as such : then you could see a lower threshold for how yourself would be treated -- and then subsequently as one got older and gained power through knoweldge and position - then treat your underlings as how you had been treated -

such that the cycle continues.

But I digress. I have no knowledge of her background really but I did question if there was some sort of cultural thing at play here also.

In any case, it wasn't pleasant to watch. I can say that at the least.

I've been there for 10 years+. I'm a permanent staffer. I've seen lots of things - and it's not like I have a fear of job security. I was there when that consultant arrived - and was new - and she's still there and I'm still there too. She knows me (to an extent). The registrars and juniors however, are relying on their consultants for references, -- they have no security. They're still training in programs - there's a disconnect somewhere and an unfairness that doesn't sit right.

I can be questioned and told - and while I'll always feel bad if something is missed etc. -- but my level of fear is much lower. I wonder if the consultant realises.

Or perhaps she thinks she's doing him a favour. Better point out his errors now, rather than let them fester. Surely there is a politer way to do things....

Is that the correct term?

It's bed time. I have a booking in appointment with the midwives for kiddo no. 2 tomorrow at the eye wateringly early time of 07:30.