Tuesday, September 11, 2007


She was a very sweet little old lady and her only current serious medical problem was that she couldn't swallow effectively. She had failed more than one modified barium swallow test.

She'd come to us initially with respiratory failure and she had been intubated for a few days. The residents felt that her swallow reflex would recover after a while and that insertion of a PEG tube would be overkill.

She was basically homeless but compliant with her medical regimen and she always showed for her clinic appointments, but pushing a grocery cart
around town successfully and maintaing an abdominal feeding tube were quite different things. If anyone could do it she could.

But it was decided to send her off to a skilled nursing facility to see if her swallowing difficulties resolved and in the meantime she'd be fed through a nasogastric tube. That seemed fair. And realistic.

An hour before she was due to be transported to the skilled facility her duotube got loose and drifted up to her throat. She was out walking around the unit when this happened. I didn't want food formula dripping into her lungs so I immediately pulled the tube and let the resident know that I'd be sinking a new one.

He was concerned about the timing, as I was. The tube went down easily enough and the X-ray said it was okay to use but it wouldn't flush: it had kinked in the stomach instead of passing into the duodenum.

I can stick it in someone's nose but since I do not myself have X-ray vision I'm unable to direct the tube right through the stomach into its outlet to the duodenum. Oh well.

We pulled it (nurses always say "we,") and sunk anothe. The repeat X-ray said we were a little short of the duodenum so the resident on-call ordered to advance it and get another X-ray. Okay. Done.

Of course by this time transport was here to take the patient to the skilled facility. We weren't ready. I made a few phone calls. Then the radiology guys called to tell me that they wouldn't do another X-ray for four hours because of hospital policy.

Hospital policy.

I told the technician that we wanted to get the patient to a skilled nursing facility but he was adamant.

Calls to the resident and our evening nursing supervisor were unfruitful. Radiology wouldn't budge. There's probably some federal regulation about waiting before you irradiate a patient again. Anyways, we had to wait.

In the meantime I'd sent all my other patients out and the empty beds were filling. Admissions mean paperwork, and paperwork means stress, so I was very busy taking report on the new patients and settling them in, as well as reporting to the oncoming night shift nurses who had begun to show up.

The moral of the story is that because of "hospital policy" regarding repeat X-rays the patient had to spend another night in the hospital, taking up a bed that could have been occupied by an actually sick person.

I'm not complaining. I'm describing. I guess you had to be there.


Eli Blake said...

At least this isn't Los Angeles.

That's where they'd dump the homeless person on skid row, no matter what their condition was.

Arizona hospitals are still civilized.

Gwen said...

I'm running into protocols right now. Somebody refuses to move outside them. Makes no sense when describing this so vaguely, but suffice it to say, "I know what you mean!"

NocturnalRN said...

Makes no sense sometimes-those "policies".