Monday, November 18, 2013

When PICU Parents Get in the Way

Ever taken care of a patient and you do everything you can for them??? Only to realize that the "everything" list is completely shortened because the parents just keep getting in the way!?

This hasn't happened to me in quite awhile...until last night.

Around midnight (yes, great timing...JUST as I was getting ready to leave!), I get a CAT page.  I think I've talked about our CAT calls before, but just a little refresher:

CAT = Critical Assessment Team

Anytime a physician, APN or nurse on any unit (outside of the PICU) feel that they want a "PICU Consult" or another set of eyes on their patient for recommendations, or perhaps a transfer to the PICU, they call a CAT call. 

Generally APNs in the PICU respond to these calls (although on some days that we are completely slammed, the fellows can step in if they are not swamped as well!).

We go up, evaluate the patient, and either decide that the patient needs to come down to the PICU, or they are stable enough for the floor service but we can give them further recommendations on what to do. 

While I really was terrified and hated these when I first started as an APN, I'm learning to love them more and more.  It really brings out the autonomy and critical thinking out in my practice.  And certainly as I become more knowledgeable, they get a bit easier.

Until last night!

As I said, I got the page right as I was getting ready to leave.  So of course, I wanted to get up there, decide if the patient needed to come down, and get out of there ASAP!

Almost 2 hours later, I was finally ready to leave for home : (

So what took so long for a process that typically takes 15-40 minutes???

The Parents of the Patient! That's what happened!!

The floor team called the CAT because they were concerned about the patient's neurological status that had been waxing and waning over the last 3 hours that the patient had been there.  I was getting the patient's history from the physician which included fevers, headache, neck pain, decreased appetite and overall lethargy for 4 days. 

My next question was what had been done in the ED and on the floor look into this.  The answer? "Weeeeelll.....not much."

I didn't really get it *what do you mean "not much" has been done??* so I re-phrased.  Off the top of my head, in a patient with these symptoms, I would be concerned about several things, but the top of my list would be meningitis.  Have you gotten a head CT, and done the LP?  What about antibiotics??

So this is where the story got interesting.  The ED apparently had to convince the parents of this patient (that sometimes woke up, sometimes not so much!) that he was actually sick!  Despite several attending physicians discussing at length with the family, they ultimately refused everything except the head CT (which was normal).

So no LP, no antibiotics, no further testing! Done.  They almost took the patient home, but the ED physicians said they would not allow that b/c their son truly was sick and needed medical attention.

So here I am, about 6 hours later doing a thorough neurological examination and determining that this patient now needs to go down to the PICU, mostly for hourly neuro checks (which is too much for our floor nurses when they have a larger patient load than PICU nurses). Ohhh boy, the parents did NOT like that!

Nor did they appreciate that I stated that he really did need an LP.  And antibiotics.  And once again, they flat out refused.

In their minds, their son was sick, but was something that he would need to fight out on his own.  And they though he truly wasn't that sick.  But he was!!

So it was a very long, very drawn out process to get the patient down to the ICU.  Ultimately, I wrote my CAT note (detailing very thoroughly what I had recommended, and that the parents were refusing most of it along the way), and had to hand off this hot mess to the team that would be there the remainder of the night.

So here are 2 parts of the PICU that can be hard or frustrating:

1.) When things are unfinished, or unresolved, it is so unsatisfying just leaving, and not really knowing the outcome right away.  But for the sake of my sanity, and the fact that I was exhausted, I did leave.

and 2.) When parents get in the way of doing what you know needs to be done medically for the patient.

So while I have no idea what happened today, I look forward to going back tomorrow night seeing what was ultimately decided among the family and the medical team.  That will help to resolve the frustration of #1.

As for frustration #2...unless we take over legal custody because the parents are truly harming the child (which is a much longer and drawn out process than sometimes seems necessary!), parents such as this will continue to be parents just like this.  And while I can't do anything to change them in the short term, I can continue to try my best to help them understand what medically would be best for their child.

And ultimately, I will continue to provide the best care that I possibly can for them.  Doing everything I possibly can to get this patient back to their healthy former self, and out of our PICU!


  1. Hey Dana, I have been following your blog for over a year. I am a PNP in a 12 bed PICU. I started about a year and a half ago. It has been great and reassuring to read your blog and understand exactly how you feel be/c I'm going through the same thing. I was just wondering if you were planning on going to any conferences next year or if you had one that you recommended. I went to the pediatric sedation conference last year and really loved it. We are responsible for covering the sedation service about 25% of our time. There are no fellows in my unit, just NPs, attendings and 2nd and 3rd year residents. We get a lot of autonomy. I was considering going to the pediatric critical care pre conference in San Francisco in Jan but I'm not sure. Any recommendations?

  2. As a nurse, I have had my fair share of reluctant relatives and patients like these. I really hate it when parents take their child to a health facility and refuse every management a nurse of physician should do for their child. Like they expect their patients to improve just by staying at the hospital, and when worse comes to worst they would blame nurses and physicians.

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  3. I was wondering, would you ever get your DNP? -Jessica

  4. That seriously sounds super frustrating!! I feel so sorry for that poor baby.

  5. Soulshine123- I've always worked in a place with fellows so I've wondered what it would be like to have only residents. I'm sure you get a lot more procedures than we do...but on the other hand I learn so much from the fellows! As for conferences, I've heard SCCM and the pre-conference is incredible so if you can do it in Jan I thinl that would be great! I wanted to go last year and this but couldn't for various reasons. I really want to go in 2015.

  6. Jessica- I've thought about getting my DNP but have decided that right now it's not for me. I'm actually going to do a post on it soon b/c several people have asked why or why not. That will give you a more thorough answer, but for now my answer is no b/c it wouldn't change anything other than my title (no change in job description, salary, etc).