Thursday, March 23, 2017

"Everyone is doing their best" their best at times was pitiful

Being the only parent around for your kids has it's pluses and minuses.  One minus is that when you are a mother with your child in critical care, eventually you will be outnumbered.  There will come a time when so many mistakes have been made and even though you have tried to correct them as they occur with a smile on your face, eventually, you will be labeled and you will be messed with.  This would not happen if I had a husband standing beside me, I can assure you.
Being a nurse and yet not in charge of anything including your very own child is beyond frustrating.  Knowing when procedure is broken, mistakes are made, mistakes are covered up, lies are being told and yet there isn't one damn thing you can do about it is as much a hardship as worrying about your child.  Not having Mike to talk to is still so difficult.  He lived it too, not just because he literally lived with us, but because his life depended on the medical staff too.  That kind of understanding is hard to find.  It's something that we could always take comfort in each other with knowing we both know.
Here we are in a major medical hospital, one that is awarded for it's safety as they are quick to tell you, and yet so many mistakes.... some minor, some major.......... but it doesn't matter.  The phrase that I heard with Mike and his Harvard cohorts is "we take care of our own".... that's an ICU staff in a nutshell.  They will even have it so turned around that you will feel guilty for speaking against them, afterall..... they are saving lives.  There are other sick kids in the hospital, not just yours......  speak up anyway.
There is a patient advocate available to you, but they don't report to anyone outside of the hospital.  If you try going outside of the hospital for a resolution, you need to wait until your child has been discharged.... just trust me on that one.
I list just some of them for you here:



- I always slept in a recliner by her bed so that they would have to move me to do anything with her.  So knowing that nothing was done to her, remarkably their charting still reflected Medicaid rules.
- When nitric oxide was trialed in an effort to keep her body oxygenated, I was told that it was too expensive to continue and they wouldn't be wasting resources.
- In order to feed her it was necessary to put the food and meds into her intestine instead of her stomach.  The tube became clogged and they couldn't use it.  They wouldn't do anything about it because it was "the weekend" and they would have to call the Intervention Radiologist oncall.  They refused and kept her on IV fluids instead.
- while getting nutrition in her intestines (the hole is made in the stomach but they pass a tube through the stomach into the intestines), they started at just 10ml per hour increasing by 10 every 4 hours.  She made it up to 40 when I noticed the nurse preparing to give her her medication.  They had switched from IV meds to "oral" meds after seeing that she was tolerating her feeds. However, the total volume of all the meds the nurse was giving was 120ml.  The nurse gave 120ml into her intestine within a 2 minute time frame at most.  She could not understand why this angered me.  I kept hearing from the nurse and her supervisor "she needs her meds, Mom". No one except the dietician could understand my complaint of bolusing a volume greater than she was received over an hour all within 2 minutes.  Consequently, Mackenzie was gagging and coughing .... they refused to see the connection.
- when attempting to give her food into her stomach instead of straight to her intestines, the nurse started the food going into her stomach and wanted to leave the tube for her intestines open to drain.  When I complained I heard "we need to keep her intestines open to release the gas, Mom.  You wouldn't want her gagging and throwing up".  Once again, nurse and supervisor failed to see that opening up the intestines which are BELOW the stomach would essentially be getting rid of all the food they are putting in.
- while changing her adult diaper for stool they like to just throw the dirty diaper on the floor instead of using a trash can.  This can lead to all kinds of problems, but this one time it was on the floor when her ventilator tubing fell to the ground.  The nurse picked up the tubing and turned to me and asked "what do you want me to do, Mom?". I had been talking to Mackenzie's physical therapist at the time and caught off guard I said "she needs to breathe".  In my mind that meant don't just stand there, get the ambu bag and breathe for her.  Instead, she reconnected the ventilator tubing that had just fallen to the ground right next to the diaper full of shit

-housekeeping bumped her nitric oxide tank and it alarms. The nurse in the room pages rt then leaves the room. She continues to alarm and desat with no one in the room but me. The interface display shows the nitric oxide is not getting to her. 12 minutes pass before anyone comes in the room. The RT assumes it's a superficial alarm until I tell him that she's now sating at 75 and the nitric oxide isn't getting to her. He fixes the connection and gives her 100% oxygen. The nurse never did come back into the room.
- Kenzie's midline was red. My sister was here with her during the night and alerted the nurse. The nurse said it flushed fine  (as a midline likely would) and used it to give her 4am Vanco. I arrived at 0830 and after seeing her red streaked armed and asking her nurse to have it looked at is when I hear of the night events. Her access was pulled and treated for thromboflubitis  (sp?). The nurse who dosed the vanco did not report off of the redness. 3 days later it's still ropey and red.
- the nurse removed her silver impregnated foam dressing from her cvl infected site to apply the clindamycin instead of applying it to the staph on her cheek. 
- her blood pressure cuff is never removed or rotated. I have been taking it off for skin integrity but a nurse hasn't for days. 
- she had an EEG, the next day I felt a hard lead still attached to the back of her head. I removed it an mentioned the redness to the nurse. 
-the nurses had offered to get me a parent tray, the food trays pass by me, but Nuanna at the desk has literally chased me down the hallway twice now to tell me that the covered container of pudding from the cafeteria is not allowed. 
- while on a cpap trial, she went down to 85% and was alarming. No one responded for 15 minutes. The nurses response was to change the parameter so it wouldn't alarm. I asked her not to during a cpap trial her response was "doesn't matter to me, your the one going to have to hear it." She changed it anyway after I fell asleep.

- 3 hours spent arguing with Eddie as ANP regarding bipap resulting in my requesting blood gas since we were at an impasse.  Her ph was 7.22 she went back on bipap.
- when Dr. Karsies counseled me on ECMO, my parents drove 10 hours to try to see her thinking she wouldn't live. They were denied coming up due to the flu restricted visitor list (That's also much longer story). It was resolved by a nurse allowing them only to be written up for it.
- moved to H02B to continue monitoring for ECMO. First few days all care was excellent. 
- the visitor list continued to be a problem and things were exaggerated and I contacted the patient advocate for help. For 2 days nurses and supervisors were not allowing our Pastor to visit.
- she was eventually not monitored as closely resulting in preventable problems. Such as an unmonitored temp resulting in my confrontation with the charge nurse. Kenzie's temp was inaccurately being measured and when I corrected their method she was 102.2 not 100.2. Big difference considering I was also complaining of redness at the cvl site.
- it took 3 days of elevated temps and my complaints until the cvl was pulled after an ID consult.
- Picu attending denying an infection until my picture of the puss at the insertion site. I don't believe the ID doctors would order Vanco for a superficial skin infection.
- staph infection on her face was also something I spent days trying to get addressed by the nurse until I asked during rounds if we could switch to clindamycin since it was getting worse. ID physicians felt it was connected to the cvl infection. 
-any complaints I am making are resulting in retaliation. When I complained of the temp method, the charge nurse instead complained about my not wearing a gown even though she was droplet and not contact precautions. She was not friendly. 
- after taking over a week to get the visitation list modified, the charge nurse not only refused to make the changes, she slapped my list down on doc station in the room and sternly said "we're not doing this. Someone will be in to talk to you". My friend was currently waiting to come up, she went home. 
- cpap sprints were ordered as 3 a day, in 24 hours she received none. Her breathing treatments were every 6 hours, they were consistently given up to 2 hours late. When her xray showed worse, I made a complaint. Mackenzie's care did not improve from my complaint. But the diffuser that I had been using for 4 days after being encouraged to bring it in from her nurse and rt last Saturday, became their focus and they told me the RT complained that it was making her asthma worse. Instead of reassigning her I was told we couldn't use the diffuser. If lavender was irritating her asthma, I find it difficult to believe that she can do her job here with all the disinfectant that irritates me. 
-Dr. Fitch wanted Kenzie up in her wheelchair. PT was consulted and kenzie was improving with her tidal volumes. Today, Dr. Estrada doesn't want her in her chair because you don't put an intubated patient in a wheelchair. 
- Dr. Fitch said if Kenzie continues on this trajectory she could be evaluated for being extubated. Dr. Estrada told me that she is weeks away from being extubated and that she needs a trach tube. That if she were in an adult hospital they would have already done it.
- then there are countless episodes of the nurses literally drowning Kenz because they neglect to drain her circuit before moving her. This results in not only immediate distress, but it sets her lungs back needing a higher fi02.
-then there are countless episodes of the nurses repositioning Kenz without untying her vent circuit from the bed rail resulting in the ET tube being displaced. 
-then there is the autonomy of the nurses with regard to peri area care resulting in a horribly involved yeast infection resulting in a wound care consult only to have those orders also ignored resulting in another consult. 
-then there are some nurses documenting things that they are not doing, such as position changes and diaper changes. I know of the false documenting because the charge nurse tells me what they write. 
-the autonomy given to the RT has me witnessing them providing treatments without listening to her lungs at all, let alone before or after. And no suctioning even being attempted because they are told during report that she hasn't had anything out of her ET tube.
-an RT told my sister (she stayed awake all night so I could go home) that it is because of me that she isn't getting anything out of her lungs because I won't let them use a Yanker  (bite reflex) and that I am suctioning her all wrong. (Hard to believe I've kept Taylor alive for 8 years if I were so incompetent).
-being told "it's too expensive to continue" and "we can't do that on the weekend"  or "I dont care, Mom. How do you want to do it" are other statements that don't belong in any PICU, in my opinion. 
- RT comes in the room to switch her cpap sprint over to support. It was 5:15. I asked when it was started and she answered 11:55. When I said it was 20 minutes late she said it was only 10. It took almost 10 minutes to explain to her why it would be 20 minutes late with me pointing to the clock and counting by 5. Considering math is an important component of her job, I didn't feel confident in her skills.
- an RT was standing bedside checking the vent. I told her I could hear an air leak and I thought it was coming from the MDI adapter. She insisted it was from her mouth since "that's where air leaks". Before I could stop her, she was putting air in her cuff. I could still hear the air leak she went to put more air in but I was able to stop her. The MDI adapter was open. I told her that risking the integrity of her trach (ischemic pressure) by increase the cuff pressure instead of recognizing the difference in sound was the wrong decision that she almost made twice. (There is a distinct difference in sound between oral cavity and circuit)
- rt was bedside while mackenzie was coughing multiple times. Even with me and the nurse asking her to suctioning her airway she didn't. The nurse went over and did it herself while explaining to the RT that it is best to assist pulmonary clearance while kenzie is already coughing. 
- while waiting in the hallway to speak to the charge nurse about the assignment of her night nurse (complaints from the night before I've already mentioned) I heard an alarm. I went in to see the nurse who had been wiping her butt, now suctioning her airway. When she saw me she started saying how much she was getting out of her and how "good" that was. You could clearly see that it was all the water that she had just dumped in her. Shortly after, Kenzie started running a temp again. I suspect that this is a strong suspect for an etiology. If not, it's still pretty gross.
- infectious disease wanted to test quantitative for flu by nose and et. Kenzie coughed and for the first time we had a decent specimen. I asked the nurse to see if they wanted to run cultures off of it too. She told me that they wouldn't run cultures on it because it wasn't sterile. It was sterile.... I asked them to change the Ballard first. She also said they would have to go deeper for a culture. This isn't my understanding.
- nurse Stephanie came in the room at 835 for the first time her shift. Mackenzie had been coughing and I was clearing her airway as t nurse walked in. An appropriate response would have been ... here let me do that for you followed by a reminder of how I shouldn't have to or offering to get the respiratory therapist. She did neither. Instead she attacked me verbally by saying she is documenting every time she sees me suctioning her. She went on to say that everyone is talking negatively about me out there, she isn't the only one who had a problem with me.  She argued, she raised her voice, she tried to bully me argued and threaten me, and when I spoke to the charge nurse there was absolutely no apology given. It is appalling that she is being allowed to speak to me that way. Also, she was in the room only to give meds after that. She spent at most 30 minutes cumulative in the room on a 12 hour shift.
- right at shift change it was decided to move kenzie to a different room. Because everyone wanted to be somewhere else, Kenzie's coughing spells were ignored and her sats hung around 89 -91 for the next dew hours even though she had been above 96.
- due to the set up of this new room, the parent area is to the right of mackenzie. Mackenzie is not able to turn her head to the right and I cannot see her face. Given that she is non verbal and unable to express herself, seeing her face is essential. It also means her vent circuit has been laying across her body. I spoke to the charge nurse of these concerns and was told that we could not be accommodated. I've been told today by Karla that we can be moved, it's been almost 24 hours in this room and we are still here

Imagine being all alone for 52 days having had all this happen and being completely ignored and bullied and retaliated against.  That's what it was like.  All of this bullshit on top of being scared out of my mind that my daughter might die.






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