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Back to the MICU, and back to Liverland

By Beth | April 29, 2008

So this MICU shift was very difficult after all, and it wasn’t for the reasons that I suspected. I thought it would be the tasks that got me down, i.e. not enough time to get things done. Surprise, surprise, turns out it was the patients.

Imagine a patient with End Stage Live Disease. She currently has hepatic encephalopathy and suspected GI bleeding. She was recently extubated. They usually put an oral gastric tube in and then yank it out at the same time when the patient is extubated. But then the patient continues to have this hepatic encephalopathy, which is a Catch-22 because then she is unable to swallow her lactulose, (which would help to restore her mental status.)

You attempt placing a nasogastric tube, twice, both times unsuccessfully, both times with the patient screaming at the top of her lungs. So at the end of the day, her baseline mental status hasn’t returned, and you have no way of giving her nutrition or lactulose. But she isn’t sick enough to stay in the ICU so you transfer her to the floor.

Typical situation for this disease, I tell myself, and that’s just the way it is. But I feel so frustrated, and so helpless for two reasons. (1) I CAN’T GIVE THIS PATIENT HER LACTULOSE AND THAT IS THE ONE THING THAT WOULD MAKE HER BETTER and (2) Trying to place this NG tube when she is not mentally stable enough to cooperate is very traumatic to her. And inevitably, the docs will always order a lactulose enema out of desperation. GUESS WHAT? If your patient can’t swallow a cupful of medicine, you can be damn sure she won’t be able to retain a pint of lactulose IN HER BUTT. So that never works.

The weird thing is that even though I hadn’t worked since last August, I had the exact same patient scenario: Liver Failure, recently extubated, mentally, in liver land, and unable to swallow lactulose.

Is it a failure of our healthcare system?
Is it a failure of my nursing skills to place an NG tube?
Is it a failure of our normal routine to yank out the OG tube when extubating?
Is it a failure of medicine in that we have failed to discover a better way of reducing a patient’s ammonia level (which is what lactulose does)?

In the end it doesn’t really matter because it was a failure, and I left that day feeling like I had done nothing for my patient except cause discomfort, and transfer her to lower level of care.

One thing is for sure, I vow never to complain again about working at Chez Recovery. It took a shift back in the MICU to make me realize just how good I had it there.

Topics: Blog |

4 Responses to “Back to the MICU, and back to Liverland”

1. Bobby Says:
   May 1st, 2008 at 7:22 pm

   Holy moses. What a pickle. I kind of get what you are saying. The patient couldnt eat anything by mouth, because they werent even here on planet earth. I do remember how much Ardis HATED lactulose because of the taste and I learned to put in orange juice and you cant even tell that it’s in there. I wish I had known that then. A person could sneak it into thier loved one’s juice(cranberry works GREAT). But thats not what your post was about. maybe it should be standard to install a nose tube so they can pump the lactulose down by the nasal route. The enema thing would be a messy affair, but the worst for me was in the hospital being NPO and having to drink lactulose with out anything to wash it down. oooooh.ugh. Bobby not the liver

2. ArkieRN Says:
   May 2nd, 2008 at 12:39 am

   Talk the radiology department into giving you a retention enema set-up. (They use it to keep the barium contrast in.) I always used one when I needed to do a lactulose enema.

3. UK Says:
   May 8th, 2008 at 7:45 pm

   Surviving liverland is about doing your best, not about always making things right. Every shift one week in the CCU I would come in and receive orders to extubate another patient so they could die. So it goes. It can get really frustrating having to continue invasive and painful interventions on a patient who is at the end of life except either the family or the doc can’t see that. End stage liver disease is one of those scenarios that really doesn’t have a good ending, so we are left with doing our best. And yeah, they shoulda left the OGT in, especially since with liver failure comes the loss of blood clotting factors. That makes for a messy and/or traumatic NGT insertion. Ouch.
   I like the idea of a retention enema setup thought I have never seen one. They must cost a bit more than the bucket-n-hose setup ;=)

4. Jamie Davis, the Podmedic Says:
   May 12th, 2008 at 10:12 am

   Difficult situation to be sure. I know that I try to focus on the fact that I won’t always be able to make things better because so often my hands are tied and I have to keep trying an intervention without success. I get to go home and feel like a lump until the next shift when I get to try and make a difference again.

   I try to take learning from these situations that maybe I’ll be able to apply to a later situation. I might have more success on the next NG tube. It’s interesting because sometimes I think these things run in cycles. Sometimes I think I can’t miss. I get every IV, every ET tube (I’m a paramedic, too), every NG tube. A week later, I’m feeling like the least proficient person on the face of the earth. The answer is to keep plugging along, I guess.

   Great blog. I’ll be back for sure!

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