Just the facts…..

….just get the facts. Those were the words I heard the night nurse I had just given report to tell his student as I walked away. And I can only surmise that Jeff’s student must have asked “that’s it?” A change of shift report isn’t the time for details, details are to be discovered during the head to toe assessment, by reading the chart, reviewing lab tests and, oh yeah, by working your shift! But as I walked away, I thought through the long history of reports I’ve given and received over the years, and how I’ve given and received reports. They’ve been short, sweet and to the point. To this day, I still use the format learned when I was a fresh trauma ICU nurse: Reason for hospitalization, Diagnosis, Surgeries/Procedures/Pending Procedures, Head to toe BRIEF review of systems which includes date/location of IV lines, ventilator settings and presence/location of tubes and drains. I’ve also added an additional category, “Family/Psychosocial” because sometimes it is useful to know if you have a family member who will lift up the patient’s gown and remove the abdominal dressing WITHOUT washing her hands OR WEARING GLOVES just to make sure “it’s done right.” This list might seem lengthy, but takes 5 minutes, 6 tops, but of course we stretch it out to gossip.

       Given that my patient was an end of shift admission from the ER, there really wasn’t a whole lot to include in my report. I covered reason for hospitalization (trip and fall – unknown loss of consciousness with altered mental status – read “combative”) working diagnosis ( Sepsis with bilateral lower extremity cellulitis – more like elephantitis) and past medical history (NKDA, IVDA, Hep C). I gave his vital signs, including a very truncated neuro assessment (sedated but arousable, mumbles name) as well as what was done in ER (Head CT – negative and pan cultured for temp 101.8 treated effectively with good ole soap and water). I concluded with a “good luck getting any additional info, he was also treated with 200 of Fentanyl and 4 of Ativan for his combativeness, he’s in a happy place.” All of that took 30 seconds.

        The format I use is basic, to the point, logical but surprisingly not universal. 12 years later and I’m stunned that some nurses start his/her report with whether or not the patient has a foley (pee tube). Really??? That’s where you start??? If I had any brains at all I’d create a shift report template to be sold to nursing programs nationwide. (Note to self, create shift report template) And now I’m off point, which is how I feel about details versus facts. Specifically, are facts sometimes dismissed as details?

       “No, Timbuktu is not showing any signs of life. We have him connected to an EEG which is showing seizure activity that we haven’t been able to stop.” Am I really having this conversation? On the phone? With a father?? 500 miles away??? Yes, yes I am. From this conversation I learned that Mr. and Mrs. Timbuktu have been waiting for THIS phone call for nearly 10 years. They are somewhat relieved that “it’s over.” Mr. Timbuktu explained that their son has battled depression since he was 16 and has multiple suicide attempts. Looks like this one is successful. What am I supposed to do? How am I supposed to feel when a father and mother have mourned the loss of their son so many times? Questioned their worth as parents? Wondered where or how they went wrong? When knowing is no more of a relief than not knowing? How am I supposed to feel when Mr. Timbuktu gives his consent to stop life support so that his son, Mrs. Timbuktu and their 3 other children, can finally be at peace but a certain neurologist believes that HE can save this boy’s life? Believes that Mr. Timbuktu is naïve and giving up too quickly? Who adamantly opposes and arrogantly dismisses the parents’ point of view? Clearly Dr. Narcissist wasn’t concerned about the details.

       If I believe what I’ve been taught (and I do), that above all else I’m a patient advocate, then I should be on the side of Timbuktu and his family. If 8 years of therapy couldn’t help this boy, then who the hell am I to think I have the magic cure? Even IF Timbuktu’s brain was able to survive the anoxia AND uncontrolled seizure activity he’d be, well, Terri Schiavo** at best. And that’s a whole other limbo for Timbuktu’s family to navigate. Sometimes ending pain and suffering is the healing, compassionate thing to do. 

       Thankfully, the neurologist was not Timbuktu’s primary doctor; therefore his opinions were dismissed as details. After we followed hospital protocol for phone consent for withdrawal of care, I walked into Timbuktu’s room and turned off the ventilator. And those are the facts, facts that in no way made the detail of turning off the ventilator any less disturbing.

**I will explain my love for Terri Schiavo in a subsequent blog.