Research Shows Hearing in an Unconscious State

We are taught early on in nursing school that our patients can hear us when they are unconscious.

Hearing is, in fact, thought to be the last sense to go before an individual dies and is present when the patient is otherwise unresponsive.

Caring of our unconscious patients often includes talking to them during daily care. I remember often chatting to my unresponsive patients and witnessing other nurses talking to theirs.

New research coming out of the UK shows us that vegetative patients can indeed hear.

Researchers performed brain scans on patients in a vegetative or minimally conscious state.

The patients were asked to perform mental tasks.

Researchers discovered that some individuals were able to control brain activity in a way that suggested signs of awareness and cognition.

In one case, the individual was able to communicate yes and no via a fMRI. In other cases, patients were able to show changes in brain activity when responding to researchers.

The authors conclude:

“A small proportion of patients in a vegetative or minimally conscious state have brain activation reflecting some awareness and cognition.”

“Careful clinical examination will result in reclassification of the state of consciousness in some of these patients,” they added, and suggested the “technique may be useful in establishing basic communication with patients who appear to be unresponsive”.

The study was published Feb 3, 2010 in the New England Journal of Medicine, NEJM.

Nursing Stories: The MVC

I was with my mother driving back from a visit to Port Perry, Ontario. It was late summer. I rolled the window down, and watched the rows of corn.

I could see black smoke as we approached an intersection. We drove up and stopped. Cars had stopped and people were climbing the roadside barrier. There was a steep hill and then the cornfield. At the bottom two crumpled cars sizzled, their black smoke rising into blue sky.

In the closest car, I could see a man. He wasn’t moving.

My mother and I climbed the barrier.

The man had a square shaped, quarter sized hole in his forehead. A woman was trying to give CPR, but it was difficult. Someone told her not to move the man. He still had his seat belt on as she provided CPR.

People were discussing an elderly couple in the other vehicle. One was unconscious, and the other they thought was dead, perhaps from heart attack.

I could only observe. I had no knowledge or skill.

Later, the EMS arrived and plucked the injured from the scene and sped away.

We returned to the car and drove home.

I can’t say that it was at this point I wanted to become a nurse, but it motivated me.

Case Study: Blood Pressure Drop

Taking care of a patient in their 40’s in with nausea/vomiting/diarrhea x1 day and stomach pain for 3 days. The physician ordered  CBC, Chem 7,  LFTs and an abdominal XRay. Blood work came back completely normal. XRay came back normal according to the radiologist, but the bowel looked bloated.

Patient has a history of Crohn’s, and it was decided that the patient had an exacerbation of the disease.

On arrival BP was 102/69; SAT 96% on room air; resp rate 18; pulse 101, afebrile.

Patient was prescribed morphine for pain. I gave 2mg morphine and the patient’s blood pressure dropped to 98/75.

Other drugs included antibiotics, antiemetic and pantoprazole.

Patient’s pain continued, and I gave two more separate doses of 2mg of morphine, spaced about an hour apart. Each time I administered the drug her blood pressure dropped.

The patient’s lowest reading recorded was 79/45. The patient was ordered another 500cc bolus of NS that was draining at the end of shift and her blood pressure was on the rise again.

The patient had no urine output since time of admission. No edema. Lungs clear. No vomiting since time of admission except just before end of shift and vomited less than 2cc of bright red blood. Her hemoglobin was normal.

I know morphine can drop blood pressure. But was there another explanation for the patient’s BP drop?

I’ll update this case study in about a week.

Disclaimer

Physician’s Assistant Versus RN: A Question of Autonomy

One of the primary differences between an RN and a PA (Physician’s Assistant) is an ability to act with autonomy.

Nursing is an autonomous practicing profession accountable primarily to the patient.

On the other hand, a “PA is a physician extender and not an independent practitioner” (source).

An extension of a physician’s expertise would be valuable in the Canadian health care system, especially in the context of a physician shortage, and in many ways, the PA allows the physician to be practicing in two places at once.

But there are inherent dangers to practicing medicine without the freedom of autonomy.

One of the roles of the RN is to challenge the physician, if needed, when an action is deemed unsafe or unfavorable to a patient.

If patient care is in question, the nurse is accountable to the patient. It is his or her  professional responsibly to advocate for their patient, even if that means rejecting a physician’s order. The nurse functions in this manner without fear of disciplinary action from the physician.

Since the PA is directly accountable, an extension of, and under direct control of the physician, they potentially forfeit the ability disagree with and not act on a physician’s order.

If a PA decides not to follow an order that they question they potentially face disciplinary action from their managing physician.

Would this  relationship of direct control sway the PA’s decision to refuse a bad order or action?

It would be better to see a PA’s take on a independent, autonomous practice, but then, they would not be much different from a nurse.

PAs  are gradually being introduced into the Canadian Health Care system.

In Ontario, there is currently a two-year demonstration project where PA’s have been introduced into approximately 20 hospitals (source). The PAs are placed in areas where there are chronic staffing issues (source).

“Historically the PA’s role was developed within the Canadian Forces Health Services to provide a full spectrum of medical care. Civilian PAs are practicing in Manitoba and in Ontario where they have been integrated in the health care system since 2006” (source).

PA’s conduct patient interviews, take medical histories, perform physical examinations, perform certain controlled acts delegated to them by a physician and provide counselling on preventative health care (source).

Nursing: A Pain in the Back

Nurses suffer from back pain more than any other profession. That list includes construction workers.

The two main risks for back injury are the usual suspects; lifting and transferring patients.

When one considers that most patients weigh over 100lbs, and then considers that nurses move and reposition patients by pushing, pulling, turning and lifting multiple times over a 12-hour shift, it comes as no surprise that back injuries are so common.

As for interventions, a 2007 systematic review found that there was “a lack of high quality studies and infrequent trial replication resulted in no strong evidence for or against any intervention method. Whilst no definitive statements can be made, moderate evidence from multiple trials suggests that multidimensional strategies are effective.”

Most likely the hospital you work for has a policy for lifting and transferring patients that may be worth taking a look at.

A few of the interventions that the study points to, include exercise strategies and ongoing education on proper lift and transfer techniques.

However, from my experience so far, nurses I’ve worked with know how to protect their backs but often fall into bad habits.

For example, we had repositioned a patient a little too far to the head of the bed then all grimaced when an experienced nurse suddenly stepped to the bottom of the stretcher and proceeded to drag the patient back, using the bed sheet, on their own.

I am no different. I have often found myself taking on a poor transfer or lift simply by not thinking about it first.

Some of the nurses I work with who have been working for multiple years already have severe back pain. I know one nurses, under 30, who will no longer be able to work for much longer in our area. Another has lost sensation in her parts of her legs and feet due to a recent back injury.

After waking up from a number of shifts now already with a stiff back, I have adopted to take on an exercise routine that includes strengthening my core muscles. I hope it helps.

I also plan not to fall into bad transfer /lift habits as it doesn’t take much to injure one’s back.

Patients and Their Amazing Veins

I’ve completed a number of IV’s and blood draws since I started in the ED, now about two months ago. The thing that strikes me as fascinating are the multitude of patterns of human veins.

Not only can veins be completely different in size, palpability, and arrangement between patients, they are also often quite different from one arm to the next.

Moreover, veins have can have a life of their own. Some veins literally roll away from the needle point, and I have found myself often chasing them down. Other veins vibrate when poked while others make a high pitched-squeal like sounds.

So obsessed with veins I’ve been lately, I caught myself starting at peoples arms.

Hmmm, I think. Nice plump veins….easy poke. (poke is nursing slang for needle insertion).

“Oh, you have nice veins,” I say somehow finding satisfaction in the potential that one may have quick and easy venous access.

“Thank you?” they say uncertainly.

Human anatomy — fascinating.

Crazy Team Nursing

I worked in an area that uses a form of team nursing today, and worked my ass off with no real feeling of connection with my patients.

Continuity of patient care is thrown out in order to use fewer nurses to cover greater patient volumes. Ideally the patients are less acute, and for the most part, they are. However, when the acuity or volume increases, as it so often does, the nurses in the area become overwhelmed.

It is a good way to practice skill-based nursing, but I much prefer one-on-one nursing.

CRNE Tips – #1 Don’t Panic….

That said, I wrote the October ’09 CRNE. Here are a few brief  suggestions to make sure you pass.

According to the CNA stats on past exams, most people pass. But don’t underestimate the importance of solid preparation.

• Get a good guide. If you can afford it, get more than one. I used Mosby’s, who have an updated guide in stock at Chapters. Make sure you check the published date though. For example, the orange Mosby is the older one…it’s still a good guide if you bought that one like me. The newer one is, I believe, blue and white and thinner.
• Get the CRNE guide from the CNA and go through it from start to finish more than once. I went through it twice and once more with a fine tooth comb.
• Go to a seminar. I attended a one day seminar by the authors of the Mosby guide. It is a good way to improve your confidence and they have some encouraging hints and tips that help you on exam day.
• Study. I studied for a month and a half before the exam. I know a bright nurse who did well in school but failed the exam. Why? They didn’t study. So study.
• Do as many multiple choice exam type questions as you can. The guides are good for this and it gets you used to how they might ask the question.

To Trendelenburg or not to Trendelenburg

The Trendelenburg position, where the pt is inclined, flat on the bed at 45 degrees so that the legs and pelvis are  higher than the head, is used often in hospital for  hypotensive patients and those in shock. A 2008 review however noted that “research findings do not provide strong support for the use of Trendelenburg positioning as an intervention for hypotension.” The review goes on to state Trendelenburg should be avoided until large scale studies can be undertaken.

On the other hand, the passive leg raise test is clinically relevant for improving blood pressure.

Originally, Trendelenburg position was used to pull the intestines away from the pelvic cavity to get better access to the pelvic organs and was named after German Surgeon Friedrich Trendelenburg. No mention of blood pressure. However, it seems an intuitive jump.

The position is actively used in hospital and is still taught as an effective nursing intervention for hypotension. Anecdotal evidence suggests short-term blood pressure improvement can be obtained using Trendelenburg.

So, should we throw it out all together? Is the position useful in some cases and not others? I’m interested. I will keep my eyes open for updated research.

My First “Oh Crap!” Moment

I administered morphine to a patient and his blood pressure dropped like a stone. 201/80 all the way down to about 80/39 over about 20 mins.

The patient had pain from a bone break 5/10 but that’s it, as far as we knew.

We put him on a NRB (non-re-breather) and flattened him out and he stabilized quickly to 140/80.

I know morphine can slow breathing and drop BP, but I hadn’t realized it could drop a BP so quickly.

I’m glad the patient was OK but the experience gave me quite a shock. I half expected his BP to keep dropping.

It’s normal for morphine to drop BP quite low. I just didn’t think it would do it so rapidly from so high up.

I’ll file this experience under very good learning.