Skin changes at end of life – preventable?

Posted on January 27, 2012 by Pat Iyer

Kennedy terminal ulcer, skin changes at end of life, pressure sores, pressure ulcers, decubitus ulcersSkin changes at the end of life – appearance
Also known as Kennedy Terminal Ulcers, these are a specific subgroup of pressure ulcers that some individuals develop as they are dying. They are usually shaped like a pear, butterfly, or horseshoe, and are located predominantly on the coccyx or sacrum (but have been reported in other anatomical areas). The ulcers are a variety of colors including red, yellow or black, are sudden in onset, typically deteriorate rapidly, and usually indicate that death is imminent.

Physiologic changes that occur as a result of the dying process (days to weeks) may affect the skin and soft tissues. These changes may manifest as observable (objective) changes in skin color, turgor, or integrity, or as subjective symptoms such as localized pain. Here is the medical legal issue: clinicians assert that these changes can be unavoidable and may occur with the application of appropriate interventions that meet or exceed the standard of care.

Dr. Alois Alzheimer was on call in 1901 when a 51-year-old woman, Frau August D, was admitted to his asylum for the insane in Frankfort. Dr. Alzheimer followed this patient, studied her symptoms and presented her case to his colleagues as what came to be known as Alzheimer’s Disease. When Frau Auguste D died on April 8, 1906, her medical record listed the cause of death as “septicemia due to decubitus.” Alzheimer noted, “at the end, she was confined to bed in a fetal position, was incontinent and in spite of all the care and attention given to her, she suffered from decubitus.” So, here we have the first identified patient with Alzheimer’s Disease having developed immobility and two pressure ulcers with end stage Alzheimer’s. In our modern times, end stage Alzheimer’s Disease has become an all-too-frequent scenario with multiple complications including SCALE (Skin Changes at Life’s End).

Causes of skin changes at the end of life
When the dying process compromises the homeostatic mechanisms of the body, a number of vital organs may become compromised. The body may react by shunting blood away from the skin to these vital organs, resulting in decreased skin and soft tissue perfusion and a reduction of the normal cutaneous metabolic processes. Minor insults can lead to major complications such as skin hemorrhage, gangrene, infection, skin tears and pressure ulcers that may be markers of SCALE.

Are skin changes at the end of life preventable?
Skin changes at life’s end are a reflection of compromised skin (reduced soft tissue perfusion, decreased tolerance to external insults, and impaired removal of metabolic wastes). When a patient experiences SCALE, tolerance to external insults (such as pressure) decreases to such an extent that it may become clinically and logistically impossible to prevent skin breakdown and the possible invasion of the skin by microorganisms. Compromised immune response may also play an important role, especially with advanced cancer patients and with the administration of corticosteroids and other immunosuppressant agents.

Skin changes may develop at life’s end despite optimal care, as it may be impossible to protect the skin from environmental insults in its compromised state. These changes are often related to other cofactors including aging, co-existing diseases and drug adverse events. SCALE, by definition occurs at life’s end, but skin compromise may not be limited to end of life situations; it may also occur with acute or chronic illnesses, and in the context of multiple organ failure that is not limited to the end of life.

Dr. Diane Krasner

Modified with permission of Dr. Diane Krasner, a coauthor of Skin Changes at Life’s End, SCALE Final Consensus Statement, October 1, 2009

Legal perspective on skin changes at end of life
What you’ve read is the medical perspective. There are attorneys who dispute the existence of SCALE and see it as a handy way for a facility to defend the development of a pressure sore. Join the controversy on February 27 and March 5, 2012. Dr. Diane Krasner provides an intimate and detailed look at pressure ulcer causes and cures in a multimedia course that will take place on February 27 and March 5. Set aside the day of February 27 to join us for an interactive course, and complete the course the evening of March 5. Reserve your spot today. Can’t join us on either date? Get the on demand recordings of Pressure Sore Case Analysis and Reports here.

When you register for the course, you will receive 10 articles loaded with essential information about pressure ulcers, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an individualized optional critique of your report. Sign up for Pressure Sore Case Analysis and Reports here. Early bird pricing ends February 13.

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Pressure Sores and Damages

Posted on January 24, 2012 by Pat Iyer

pressure sore pain, pressure ulcer pain, decubitus ulcer, Dr. Diane Krasner

Pain Scales Use with Pressure Ulcers
Pain from pressure sores can sometimes be measured. A variety of pain scales are used to measure that which is subjective. The universally accepted measurement techniques are the utilization of visual analog scales (10-cm line with no pain at one end and worst possible pain at the other end, and the patient places an ‘‘x’’ at the appropriate point), Faces Pain Scale (various levels of happy and sad faces), or the numerical rating scale. The numerical rating scale asks if the patient has any pain on a 0- to 10-point scale with the anchors that 0 is no pain, 5 is the pain associated with a bee sting, and 10 would be the amount of pain experienced by slamming the car door on your thumb. Even in patients who cannot respond verbally, such as those with dementia, pain still needs to be assessed. There are pain scales for these patients that rely on nonverbal clues such as facial grimaces and pupil dilatation. (Assessment of pain for people with dementia can be found at www. hartfordign.org.)

A patient with a pressure sore
Bill is a 70 year-old-man who developed paraplegia. During his prolonged hospitalization, a stage IV pressure sore formed. One year later, it is still present and it dominates his life at home. Pressure sores may have a huge impact on the quality of a patient’s life. There is a financial impact of prolonged treatment – dressing changes, supplies, debridements, and flap surgeries. There is a medical impact of complications and risk of death from sepsis. There is a personal impact of physical restrictions, social isolation, loss of independence, and emotional problems. There is dealing with odors and limitations on the length of time one can sit. But pain is one of the biggest factors that affects the quality of the patient’s life.

Causes of Painful Pressure Ulcers
Pain levels should be recorded before dressing change, during dressing change, and after dressing reapplication. Krasner has defined wound associated pain at dressing change (intermittent and recurrent) versus incident pain from debridement or the persistent pain between dressing changes. Woo carried the Krasner concept further and demonstrated that anxiety and other patient-related factors could intensify the pain experience.
The Wound Associated Pain Model of Woo and Sibbald defines pain from the cause of the wound as often being persistent or present between dressing changes and distinguishes this pain from the pain associated with local wound care components (dressing change, debridement, infection, lack of moisture balance). All of these factors can be modified by patient-centered concerns, including previous pain experience, anxiety, depression, mobility and awareness or lack of comfort with the setting, and the procedure or treatment plan. Pain is an under-recognized and undertreated component of chronic wound care that has been demonstrated to be more important to patients than healthcare professionals. Causes of pain at dressing change include the dressing material adhering to wound base, skin stripping from strong adhesives, and aggressive trauma from cleansing technique (eg, scrubbing with gauze).

Many patients also express chronic persistent pain between dressing changes even at rest. A systematized approach should examine other systemic and disease factors that may play a role in precipitating and sustaining persistent wound-related pain. Common systemic factors are bacterial damage from superficial critical colonization or deep and surrounding compartment infections, deep structural damage (eg, acute Charcot foot in patients with diabetes), abnormal inflammatory conditions (eg, vasculitis, pyoderma gangrenosum), or periwound contact irritant skin damage from enzyme-rich wound exudate.

Impact of Pressure Ulcer Related Pain
Bill has a Morphine pump in his abdomen to deal with his pain. He takes supplemental Morphine by mouth. There are times he sleeps all day and is awake all night. The impact of chronic unrelenting pain can be devastating, eroding the individual’s quality of life and constituting a significant amount of stress. Increased levels of stress have been demonstrated to lower pain threshold and decrease tolerance. The result is a vicious cycle of pain, stress/anxiety, anticipation of pain, and worsening of pain. Increased stress also activates the hypothalamus-pituitary-adrenal axis, producing hormones that modulate the immune system compromising normal wound healing. Medications including nonnarcotic for moderate pain and narcotic analgesics for moderate to severe pain are required to treat severe pain as outlined below. A consult from a pain and symptom management team may be considered. Comprehensive management should also include careful selection of atraumatic dressing, prevention of local trauma, treatment of infection, patient empowerment, stress reduction, and patient education.

Modified by Pat Iyer with permission from Dr. Diane Krasner, coauthor of Special Considerations in Wound Bed Preparation 2011, an Update, Advances in Skin and Wound Care, September 2011

Dr. Diane Krasner

Dr. Diane Krasner provides an intimate and detailed look at pressure ulcer causes and cures in a multimedia course that will take place on February 27 and March 5, 2012. Set aside the day of February 27 to join us for an interactive course, Pressure Ulcer Case Analysis and Reports, and complete the course the evening of March 5. Reserve your spot today. Can’t join us on either date? Order the on demand recordings of Pressure Sore Case Analysis and Reports here.

When you register for the course, you will receive 10 articles loaded with essential information about pressure ulcers, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an individualized optional critique of your report. Sign up here for Pressure Sore Case Analysis and Reports.

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Interruption Awareness and Medical Errors

Posted on January 20, 2012 by Pat Iyer

This is a great explanation of how the overload that occurs in a nurse’s job can result in distraction and medical errors.

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Healthcare fraud: shaking the foundations

Posted on January 17, 2012 by Pat Iyer

healthcare fraud, False Claims ACt, nursing home fraud, cardiac stents fraudHealthcare fraud is big business, which costs the US Government and Americans huge dollars. There are several federal statutes that tie into making fraud a crime. These criminal statues include

  • Health care fraud
  • Theft or embezzlement in connection to health care
  • False statements relating to healthcare matters

    • Obstruction or criminal investigation of health care offense

    The False Claims Act requires the defendant to submit a claim or cause a claim to be submitted to the government that is false or fraudulent, knowing of its falsity and seeking payment from the Federal treasure. There may be damages. The penalties include a civil penalty from $5,500 to $11,000 per false claim and three times the amount of damages which the government sustained.

    Here is how nursing homes have gotten in trouble:
    The long term care provider makes payments for patient referrals. (In US ex rel Wall v. Vista Hospice Care, Inc, the court denied motion to dismiss the allegation that the hospice paid nursing home employees for patient referrals. March 2011).
    The long term care provider receives payments for referrals. (Mariner Health Care and SavaSenior Care paid $14 million to settle allegations they took kickbacks in exchange for renewing contracts with Omnicare, settled February 2010)
    Medical directors may be paid more than fair market value.

    What does the government expect of nursing homes?
    They want a partnership with Federal and State governments to detect and prevent misconduct.
    They want an ethical corporate culture.
    They expect an organization to ferret out wrongful conduct and non-compliant activity.
    They expect cooperation during investigations of an organization’s wrong doing.

    Based on handouts from Broad and Cassel, American Conference Institute, April 2011

    A few weeks ago I met a physician who told me of a fraudulent scandal at his hospital. A cardiologist was caught for performing stents on patients who were not true candidates for the procedure. He obtained a lot of money for doing the unnecessary procedures. This cardiologist was well-respected until the fraud was uncovered, and he lost his license to practice. The scandal rocked the hospital, damaged its reputation, and caused several people to leave their positions. The hospital is now for sale.

    The rippling effects of fraud and greed are far reaching. I know that as I prepare this blog post, someone is hatching a scheme to defraud or cheat or steal. If only the creativity associated with fraud was channeled into positive pathways.

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    Breaking Down the Nursing Home Chart

    Posted on January 13, 2012 by Pat Iyer

    nursing home chart, nursing home medical records, long term care chart, LTC chart, MDS 3.0 Nurses without long term care experience may be very hesitant to review one of these cases due to their lack of knowledge of these industry specific records. Once you understand where important information is located within these medical records you can use them to support your analysis of the matter.

    One of the most mystifying parts of the nursing home chart is the Minimum Data Set (MDS). The MDS is a standardized instrument used to assess all nursing home patients. It is a comprehensive assessment of the resident’s physical and functional abilities and cognitive status and includes indicators of delirium, fall history, diagnoses, wounds, nutritional status, restraint use, continence status, and more. The nursing and therapy notes and other documentation should be reviewed to ensure the information in the MDS is accurate.

    Depending on the timeframe for the care being reviewed, the chart may contain an MDS that may be either version 2.0 or 3.0. After extensive review, the Federal government released the 3.0 version on October 1, 2010. The Resident Assessment Instrument (RAI) now consists of the Minimum Data Set (MDS) 3.0, the Care Area Assessment (CAA) Process, and the RAI Utilization Guidelines. The MDS 3.0 was refined to include many changes including, but not limited to, a focus on pain assessment and discharge planning, when assessments should occur, some changes in coding, and the use of Care Area Triggers (CATs) rather than Resident Assessment Protocol (RAPs). The MDS 3.0 focuses on resident participation through multiple interviews. The “look back period”, the time frame the MDS assessment is based upon, is seven (7) days for all areas unless otherwise noted on the assessment.

    There are 20 CAA’s that can be triggered by the MDS responses. The identified triggers are used as a guideline for development of the individualized plan of care. The staff may override the trigger or decide to proceed and create a plan of care. For example, nutritional status may be triggered due to recent weight loss. However, the staff may override the trigger by indicating a recent history of bilateral above the knee amputations, thus justifying the recent weight loss or less than ideal body weight status. The CAA’s should be reviewed to ensure that all potential risks have been appropriately triggered and addressed in the plan of care.

    While the Plan of Care (POC) is not paperwork specific to long term care, it is a very critical document and must be closely reviewed to ensure every risk unique to that resident has been addressed and that the POC is individualized to the specific needs of that resident. The care plan is a dynamic tool that should be updated as the needs of the resident change. For example, if the resident is at risk for falls and the goal indicates the resident will have no falls with injury within the next 90 days and that resident does indeed fall and sustained injury, the plan of care must be updated. You should expect to see new interventions to prevent falls.

    Therapy documentation is critical to long term care cases. When a resident is involved in PT, OT or ST you will find frequent documentation which can be crucial, especially when there are few nursing and physician notes. Therapy notes will usually describe the resident’s functional ability, level of pain, subjective statements, cognitive status, and safety recommendations. Always be sure to review the therapy records thoroughly and compare these assessments to the nursing notes, physician notes, MDS, and care plan. Likewise, important information may be found in the social services notes as documentation regarding discharge plans, family concerns, and social history is likely recorded in this section.

    Don’t allow your lack of familiarity with long term care records hold you back from an interesting case review. Your knowledge of the records outlined above will provide you the ability to thoroughly understand the residents’ needs and determine whether they were met. This information is just a brief overview of a few of the records. However, part of being successful is self educating and knowing how to find the information you need. Identifying a long term care nurse that you can call with questions as needed might just provide you with the added confidence needed to say “Yes” when asked to review a nursing home case. To learn more about record reviews and how to WOW your clients check out this information on how to polish your writing skills.

    Angie Duke-Haynes, RN is President of Premier Medical Legal Consulting, LLC, co-owner of Legal Nurse Consulting Institute, LLC and co-presenter of an all new webinar on polishing your writing skills.

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    Are you writing dangling modifiers?

    Posted on January 10, 2012 by Pat Iyer

    I’ve just finished writing The Manual for Writing for Fame and Fortune. Modifiers dangle if they do not seem to be related to anything in the sentence or if they are not placed near enough to the words they modify to seem attached to those words. Dangling modifiers can be adjectives, adverbs, or prepositional phrases. (1) Ensure that modifiers, particularly those expressing action, have a clear noun to modify. Ensure modifiers appear either next to or as close as possible to the word or words modified.

    Here’s something light today. These make me laugh. They are dangling and misplaced modifiers from this site:

    http://writing.wisc.edu/Handbook/CommonErrors_BestMod.html

    The best misplaced and dangling modifiers of all time
    Oozing slowly across the floor, Marvin watched the salad dressing.
    Waiting for the Moonpie, the candy machine began to hum loudly.
    Coming out of the market, the bananas fell on the pavement.
    She handed out brownies to the children stored in Tupperware.
    I smelled the oysters coming down the stairs for dinner.
    I brushed my teeth after eating with Crest Toothpaste.
    Grocery shopping at Big Star, the lettuce was fresh.
    Driving like a maniac, the deer was hit and killed.
    With his tail held high, my father led his prize poodle around the arena.
    I saw the dead dog driving down the interstate.
    Holding a bag of groceries, the roach flew out of the cabinet.
    Emitting thick black smoke from the midsection, I realized something was wrong.
    The girl was consoled by the nurse who had just taken an overdose of sleeping pills.
    I saw an accident walking down the street.
    Drinking beer at a bar, the car would not start.
    Playing pool in the living room, the radio was turned on by Jim.
    Frustrated by diagonal movement, the set was turned off.
    Mrs. Daniel sews evening gowns just for special customers with sequins stitched on them.
    Although exhausted and weary, the coach kept yelling, “Another lap!”
    She carefully studied the Picasso hanging in the art gallery with her friend.
    Having an automatic stick shift, Nancy bought the car.
    Freshly painted, Jim left the room to dry.
    He held the umbrella over Janet’s head that he got from Delta Airlines.
    He wore a straw hat on his head, which was obviously too small.
    After drinking too much, the toilet kept moving.

    (1) Franklin Covey Style Guide, Franklin Covey, 1999

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    Legal nurse consultants: How to lose a client in one report

    Posted on January 6, 2012 by Pat Iyer

    Polish your Writing Skills course, legal nurse consulting reports, Pat Iyer, Dana Jolly, Angie Duke Haynes
    Want repeat business? Here are some report “don’ts”.

    1. Striking the wrong key
    Relying on the computer to function as the only proof reader of your LNC report is sure to miss a few common typographical or grammatical errors. An example I frequently see is the wrong word being typed, i.e. “form” when “from” should appear. A lack of attention to detail is guaranteed to have your client second guessing his request to have you review the critical evidence in his case.

    2. Blind side your client
    Do not include any references: source document, Bates numbers, literature citations. You don’t want your client to easily find the critical document or the article that supports the case theory. Attorneys really do want to search through all those medical records themselves.

    3. One and done
    Just provide the facts and your conclusion. Don’t include recommendations for the next steps the client should take. After all, the report speaks for itself. Attorneys, being familiar with the provision of health care, can easily identify just the specialty needed for an expert review. All attorneys understand the difference between a diagnostic radiologist and an interventional radiologist, for example.

    4. Missing the point
    Make your conclusion hard to find. Place it anywhere but the beginning of your report. Attorneys love to read the whole report before they learn what your conclusions are. Placing your conclusion at the beginning of your report with emphasis formatting would make the attorney less inclined to read your entire report, something to be avoided at all times.

    5. TMI*
    When in doubt, include it. It is important the attorney is made aware of all potential breaches in the nursing standard of care regardless of the relevance to the allegations.

    * too much information

    Dana Jolly, BSN, RN, LNCC is president of Jolly Consulting, LLC, a national legal nurse consultancy. She is a published author and frequent lecturer on legal nurse and clinical topics. To learn more about what you can do to present a polished, accurate report, join Angie Duke-Haynes, Pat Iyer, and Dana Jolly on February 1 and 8, 2012 for a webinar course, Polish Your Writing Skills.

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    Psychiatrist Beaten By Patient at Hospital

    Posted on January 3, 2012 by Pat Iyer

    traumatic brain injury, fracture orbit, violence against hospital staff, violent patients, Med League, Pat Iyer Damages
    Violence by patients against hospital staff is a growing concern. In a Virginia case, a psychiatrist was beaten by a patient and suffered a traumatic brain injury, a fractured eye socket, concussion and skull fracture. He is now depressed, has post traumatic stress disorder and vision impairment which prevents him from working.

    The injury
    The August 2011 Trial Magazine write up explains that the patient twice approached the doctor while he was employed at Virginia Beach Psychiatric Center. During the first encounter, the patient made statements to the physician before he was escorted away. In the second encounter, the patient formed his hand into the shape of a gun and pressed it against the doctor’s head and said “bang.”

    The patient approached the doctor at the nursing station, and beat him.

    The standard of care issues raised in this case related to the inadequate security provided. Although violent incidents occurred every few days at the facility, it retained only one part-time security guard to patrol the parking lot.

    In Shetty v. Psychiatric Solutions, Inc., the jury awarded 5.35 million. Post trial motions are pending. Case site: No. CL09-1873 (Virginia, Norfolk City Cir. Nov 22, 2010.)

    Evaluation of these kinds of cases is based on determining if an event was foreseeable. Dr. Shetty’s attorneys argued that the patient had threatening behavior, a documented history of violence and was involuntarily committed to the facility. He was placed on the lowest watch level.

    Standard of care
    Violence against staff may take place anywhere in the hospital. Emergency and psychiatric nurses are particularly sensitized to this issue, as they are more common targets. As this case shows, the facility has an obligation to protect its staff by accurately identifying the risk of violence (to the extent possible) and providing safeguards for staff.

    Med League nurses have assisted attorneys with psychiatric cases including evaluating the events in light of the standards of care, providing the relevant standards for the time frame involved, creating a chronology of events and or supplying psychiatric healthcare experts.

    Pat Iyer is president of Med League. She is very glad she does not work in a psychiatric hospital.

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    Legal Nurse Consultants: Tips for Improving Writing Skills

    Posted on December 30, 2011 by Pat Iyer

    writing skills, polish your writing skills, improve writingToday, people are using very different writing styles, not just what you learned in school from your English teacher. Informal writing has changed. Text messaging, in particular, has caused us to think in terms of brevity of communication. But the real risk in brevity is that you are going to miss things and you will not be able to fully convey what you want to say, particularly within a business environment.

    Getting exposed to poor writing is a big source of frustration for many people who work in professional fields. And there are errors and risks to people and to systems if we can’t communicate well in terms of what we know or instructions that we need to give other people.

    The ability to write fluently in an easily understood manner is not going to go out of style. There are people who see typos and get focused on the typos and say, “Oh wait a minute, let me look at that word, it doesn’t look right. Oh, she spelled that wrong.” Poor writing makes us take a few seconds away what we are reading in order to filter that through the editor in our minds. When writing is done beautifully, you don’t notice it; when it’s done poorly it jumps out and it distracts you from the message.

    Tips for Improving Your Writing Skills
    1. Do a lot of reading. Sit with a book either in paper form or on an electronic reader like a Kindle or Ipad. Notice how the author forms sentences. Do the words flow? Exposure to good writing of people who are fluent in the language improves your skills. Conversely, reading poorly written material is painful.
    2. Write a report or essay. Set your material aside for a day and then proofread and edit it. Look for places where you can compress the sentences, improve word flow, and improve clarity.
    3. Ask someone with good writing skills to be a copyeditor to help you improve. A copyeditor improves word flow, in addition to proofreading. A copyeditor will take your material and rearrange it so that it flows better. This person improves the language, grammar, and word usage.
    4. Study how the copyeditor changed your material. Incorporate those changes into your writing style.
    5. Take a writing course or an English writing composition course at a local community college or local college, or audit the course if you don’t want to take it as a matriculated student.
    6. It is important to remember you can always improve. Learn from others’ writing or critiques of your writing. Develop a thick skin and graciously accept criticism so you can learn from it.
    7. Read books on writing. One of my favorites is Eats Shoots and Leaves by Lynne Truss, a truly funny book about grammar. Also read The Language of Success by Tom Sant or Plain Style: Techniques for Simple, Concise, Emphatic Business Writing by Richard Lauchman.

    Patricia Iyer MSN RN LNCC has been a legal nurse consultant for 24 years. She is president of Med League Support Services, Inc. and Patricia Iyer Associates. She is the author or editor of over 125 books, chapters, articles case studies, and online courses. Along with Dana Jolly and Angela Duke Haynes, she is presenting a webinar course called Polish Your Writing Skills on February 1 and 8, 2012. See www.patiyer.com for details.

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    Cataract Surgery – the Easy Way

    Posted on December 27, 2011 by Pat Iyer

    cataract surgery, cataracts, Fentanyl, VersedLast month I had cataract surgery on my left eye. I returned to the hospital this month to have the other eye operated on. It was an entirely different experience. My husband and I got up at 4:30 AM to make it to the hospital waiting room at the very early time of 6:15 AM. “You’ll be his first patient”, I was told. We immediately noticed the woman who shuffled in with a walker and her husband. Her eyelids were cherry red. We also noticed the young mother and her baby, who looked to be about 2 months old. The baby was the eye patient. The mother and grandmother of the baby anxiously watched as the child was taken away for surgery. In fact, I watched every patient taken away for surgery while I waited in the holding room.

    Marking the site
    As he did last time, my surgeon again checked the dot pasted over my eye to be operated on, and wrote his initials on my forehead to mark the spot. I noticed that he politely greeted the staff, and that they responded to him with pleasantries. (It is very important for your doctor to get along with the staff.)

    You felt pain?
    When the cheerful anesthesiologist stood at the bottom of my stretcher, he shot off a series of rapid fire questions. I could tell he asked the same questions over and over – “any medical problems, do you smoke, do you drink?” Then he said, “I promise you will feel no pain and no awareness of what is happening.” “Oh, really?” I told him. “I felt pain last time.” He looked puzzled. “You did? There is no knife or needle.” I told him I don’t know what caused the pain but I did feel pain at the end and asked the doctor for pain relievers, which he would not give to me. Then the anesthesiologist looked uncomfortable and reminded me I would not have to have cataract surgery again as both eyes would have been operated on.

    The wait
    The patient with the cherry red eyelids went off to the operating room before I did, and I suspect her surgery was more involved than mine; she had the same surgeon I did. When the nurse anesthetist and operating room nurse came to get me, the nurse anesthetist immediately gave me a full 3 cc syringe of Versed (sedation) as she was wheeling my stretcher down the hall to the operating room. That seemed to be the height of efficiency. But then we waited and waited in the operating room for my surgeon to finish up with the cherry red eyelids lady. I floated in a pleasant Versed-induced haze, dimly aware of the voices of the operating room nurse and nurse anesthetist. At one point, one of them said, “She’s asleep.” “No, I am not, I can hear everything you are saying.” It got quiet then.

    Hiccoughs
    While still waiting for the surgeon, I developed the hiccoughs. “My surgeon is not going to like this”, I told them. I imagined him trying to operate on my eye while I was hiccoughing. Ever the helpful patient, I remembered that Thorazine can be given for hiccoughs and asked the nurse anesthetist if she had any. “No, we don’t have anything like that here.” The next thing I knew, I woke up. My wrists were tied to the stretcher (me, in wrist restraints!) The surgeon said, “I’m taking the clamps and mask off. We’re done.” Wow! I got to sleep through the surgery.

    Fentanyl: my new best friend
    The nurse anesthetist told me she gave me Fentanyl, a fast acting pain reliever. Fentanyl took away awareness of surgery. I saw the first surgery taking place; I did not need to see the second one too. My curiosity was satisfied. My husband helped me walk to the car, as Fentanyl made it hard for me to walk a straight line. Fentanyl also made me see double cars on the highway headed home. Fentanyl allowed me to take a nap when I got home. Fentanyl is now my new best friend.

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