True to their mantra, “Anything that can be done at the hospital, we can do right here at home”, Hospice fitted Debbi with a morphine pump yesterday.
Lets back up a bit. Lyn, our Hospice coordinator who has been (and I am sure will continue to be) a fantastic resource to Debbi, to the kids, and to me) stopped by yesterday around lunch time just because she was in the area visiting another patient. She asked Debbi how the pain management was going and after listening to Debbi, Lyn said, “I think things would be easier with a morphine pump.” A tall lady with a winning smile and a kind demeanor, Lyn grabs her cell phone, struts out of the bedroom and starts dialing like mad. Pretty soon calls are coming in on the house phone for Lyn. For a moment I felt like I was back on a trading floor in New York City. Lyn had the cell phone to one ear, the house phone to another, she was writing notes, barking out orders, and coordinating the drama that would soon unfold.
Within an hour, there was a knock on the door. Home Solutions Infusion Network was delivering the physical morphine pump. I had to sign a myriad of papers including one that says that if the pump is not returned, my credit card gets hit with a $5000 charge!. I started admiring the pump which is slightly bigger than a deck of cards. It has a provision, just like the bigger models in the hospital, whereby it squeezes the fluid line from a reservoir of medicine pushing it forward according to the programming set by the nurse in conjuncton with a pharmacist.
As I was admiring the pump, which can dose out fractions of a milligram and has a push button for break through pain, there was another knock on the door. This time it was a delivery of the actual morphine and resources to access the port in Debbi’s right shoulder.
Knock Knock. It was Margot, another of the hospice nurses here to access the port and to hook up the pump. Knock Knock… in walks Lyn. “How is it going”, she wants to know. Her actions began with calls to the doctor and pharmacist as well as to the team described already. Lyn herself came back to oversee the pump hookup and to describe its use to Debbi. It seemed that within an hour Lyn managed to contact all the parties and coordinate the operetta that concluded with the regulated flow of pain relief straight to Debbi’s blood stream. After visiting a while longer and sharing some stories, Lyn said good bye, but this was not to be good night.
Shortly after Lyn left, the pump started beeping. I looked at the display and read its error message, “Down Occlusion.” What does anyone in that situation do… first silence the alarm so it does not disturb Debbi and then call the emergency number that Lyn left me. I followed her instructions and left my call back number as requested. Not content to simply wait for the pharmacist to return my call, I figured that occlusion meant that the tubing was kinked so I straightened all the lines and convinced myself that there were no kinks. This did not restore the pump to operational mode. I wasn’t left a manual… I would guess that the team does not want people tampering with the pump although I was told that there are about 7 layers of passwords… (Between my son Aaron and I, we can break any passwords… but he is the one who know how to break this one and he is not here right now!! … could not help myself… it is an old joke). So, I looked up the unit on the internet and under troubleshooting the diagnosis of a down occlusion meant a restriction in the line between the pump and the patient. Again I went over the tubing inch by inch (ok ok.. no Niagara Falls jokes now… I promise I wasn’t drinking last night) and I discovered that in the short supply tubing that terminates with the needle that penetrates Debbi’s port, the tubing had a kink in the space where the clamp sits. The clamp is a small white plastic structure that snaps to prevent fluid flow. The dongle (8 inch run of tubing from the needle to the access connection) is delivered with the clamp snapped. The clamp was surely open now but somehow, even though it was open, it was not open fully so the constricture of the clamp opposite the kink from where the clamp’s force had been applied during shipping served to restrict the flow to the point where the alarm was triggered. I simply readjusted the clamp and the alarm cleared. 15 minutes later Jim (the pharmacist who had assisted with the morphine… I recognized his name from the arrangements that Lyn was conducting) was calling to offer assistance. He complimented me and offered some further suggestions for using the pump effectively.
As anyone who has been on or near such a device knows, the patient can press an attached button to trigger release of additional pain killer. The computer on the pump is programmed to release medication based on a slow continuous basis as well as a bolus in response to a press of the button. However, the computer is also programmed to allow a bolus release only once in a certain measure of time. In Debbi’s case, she is allowed one bolus every 30 minutes. If she presses the button more frequently, the bolus is not delivered more often than allowed. However, each button press is recorded and the nurses and the pharmacist use this information to calibrate the dosing rate of the main delivery channel. Last I checked, Debbi had pressed the button 9 times and 7 of those times a bolus had been delivered.
At around 9pm, Lyn stopped back to make sure all was going well. Her cheerful smile told me that she was indeed happy to have brought about all this assistance to make Debbi comfortable with the understanding that her teammates would be analyzing Debbi’s pain and button presses to further refine the dose rate. As Debbi settled in for the night I thought back to the mantra and decided that Lyn’s care really exceeded that which we would have found in the hospital. Plus, the hospice nurses are better looking!