Have you ever had a sense of intuition about a situation before you’ve even assessed it thoroughly? I’ve always been told to listen to my intuition, and so I try to, even though I don’t even know what my intuition is, exactly. Is it God telling me something? The Bible doesn’t really say that anywhere. Maybe it’s my mind looking at a situation and sensing or reasoning through something based on past experience of which my consciousness isn’t even aware. Who knows? All I know is my intuition has usually served me well, though I have not always dealt well with it. One particular case stands out in my mind:
I was working an evening admissions shift, as I often did early on at my job in hospice. I live fairly north in San Diego county, and I remember they sent me pretty far south, probably something like Chula Vista or National City. So there was traffic. I always knew something about the situation before I went out, though not always a lot more than a name, address, age, and diagnosis, and I remember this patient was a 50 something year old female, diagnosed with a metastatic abdominal cancer. It was dark, and I had a little trouble finding the apartment, as apartments are often difficult to find in the dark…or in the light, for that matter. I started to get concerned when I finally pulled up to the apartment, and the office was on the phone with me asking when I would get there…because the patient’s daughter was calling.
Working in hospice is unlike any other kind of nursing I’ve experienced, because you’re alone. At the hospital, if I can’t put in a foley catheter on some poor gentleman with an enlarged prostate, call someone else–call the urologist, who has special ones, or call a really experienced nurse. In a home, if I can’t do it, it’s a big big big hassle. So I did a lot of praying and plunging in. Controlling my own anxiety is critical. In a home, I’m the one who is supposed to have the answer about what we should do. I can call the doctor, or I can call another nurse for advice, but most of the time, they couldn’t think of anything that I couldn’t think of, because I was the one there assessing the situation. And I needed to figure out how to deal with it. I got used to it, and even prided myself on being able to handle a lot of stuff on my own. But in the early days, it’s a lot of pressure.
So there I was, my patient, her adult daughter, and it’s not good. She’s vomiting, and I hate vomit. I really hate vomit. She hasn’t had a bowel movement in three weeks. Yes, three weeks. Three weeks. An alarm goes off in my head. Three weeks. Not only is that abnormal, but that’s really bad. She’s vomiting, so that means that she is completely blocked, and it’s going the other way. Not to be too gross, but some people end up vomiting stool. And you don’t want to do that at all.
That’s where my intuition kicks in. It’s telling me that she’s blocked by cancer, and we’re not going to be able to deal with this easily at home.
So I called the doctor. I figured I would page him, take her vitals and assess her, and he would call me back by the time I was done (since it was evening, they didn’t often get back to you really quickly). Well, he called me back in less than five minutes. I felt that she should be moved to our inpatient center, that she was in crisis, and I told him so. He asked me, “is she impacted? Did you assess her?” No, I hadn’t, and I hadn’t had time to before he called me back. I said no. I don’t know what all I said to him, but nothing sounded quite right. He told me he would find it hard to trust my skills if I hadn’t even done that, that I seemed incompetent. So my heart sank, I felt ashamed, and I said I would check to see if she was impacted and call him back.
Impaction is when a person gets so constipated, and stool gets so backed up in the rectum that the person is physically unable to get it out themselves. The process for assessing an impaction is very sophisticated and technical; it involves sticking your finger up the rectum to see if you feel a lot of stool. If you do, she’s impacted. The process for dealing with impaction is even more sophisticated and technical. It’s called disimpaction, and I’ll leave that to your imagination. It’s not pretty, and it’s not fun, for the nurse or the patient. Please, God, never let me get impacted.
I checked her. She wasn’t impacted. I gave her nausea medicine. I called the doctor back. He didn’t trust me, and he didn’t believe that she wasn’t merely constipated. Maybe he didn’t have a bed for her in the inpatient facility, I don’t remember, but I think he just wanted to keep a bed available for a patient who wasn’t assessed by a cuckoo nurse. He sent me some suppositories. Still ashamed, I didn’t argue. They weren’t going to do anything, but I wasn’t going to get anywhere that night with him anymore. I lost trust. It was my fault.
All I could do was give her daughter instructions on how to get through the night, and send another nurse out the next day to see her. I did that. They were disappointed that I couldn’t fix it, and I was too, but they weren’t mad at me. At least they knew we wouldn’t abandon them. The nurse came the next day and promptly sent her to our inpatient center. I don’t know what caused her constipation, whether it was fixed or not. I am pretty sure that she stayed in the inpatient center a couple weeks until she died, so it probably was not easily fixed. My intuition, as inconvenient as it was at that time, may have been right. I just needed to learn the self-confidence and assertiveness to back myself up, admit how I was wrong, and move on from there. It was a good lesson to learn.