Disappearing Nurse

I looked up from my charting that night as an incessant stream of words kept drawing my attention.

“Mrs. Smith?  Mrs. Smith?  Can you hear me?  C’mon open your eyes for me!”  incessant pleading, repeating quicker, voice rising in timber and urgency.

I look over at tele, nothing ringing, nothing out of the ordinary.  As I walk across the nurses station I see two colleagues at the bedside of one of our new admissions.  Like a tag team they’re trying to get Mrs. Smith to respond.  And it isn’t working.  She is just laying there, limp, barely moving any breath into the shriveled shrunken chest.  I start to get that sinking feeling in the pit of my stomach.  Something is definitely not right.

“Hey, what’s going on?”  I ask walking into the room.  Looking around I see a manual BP cuff, fluids up and going, oxygen on, but no purposeful signs of life.

“She’s not responding to us.”  says Not-so-New-Nurse (NsNN).  She’s good, a little lacking in confidence in herself, but usually when she asks a question these days she already knows the answer, but is not yet confident to believe she has the correct answer.

“Merly was trying to get some vitals but the Dynamap isn’t reading so I came over from my patient in bed 2 to help her out.”  she continued.  “Now she’s not responding to us.”

I look around, Merly is nowhere to be found.  Not surprising.  It always seems that when her patients are going bad she finds reasons to step out.  It’s “Oh I need this”, or “I went to call RT.”  She’s been at this a long time and is a very competent nurse, she always seems to disappear at the worst times.

Outside the room another charge nurse and the house supervisor have come over.  “Do you need anything?  Want us to call the RRT?” they ask, worried looks directed my way.  They both know my reputation as a black-cloud.

“Not quite yet, let’s see what’s going on.”  I say.

I step up to the side of the bed, grab a frail limp wrist feeling for a pulse.  It’s there, thready weak, fluttering away under my fingertips.  “Mrs. Smith…”  I say squeezing on her nailbeds.  Normally I would be rubbing my knuckles along her sternum, but as I look I can count the ribs, I might snap them if I rub too hard.  Mrs. Smith is a dictionary definition of cachectic, eyes sunken, skin a wan yellow almost waxy pallor, thin stringy hair, the look of someone who has not eaten much, if not anything in a long time.  She had come in right before shift change with a diagnosis of hypokalemia and failure to thrive, or otherwise malnutrition.

As I’m thinking this through I’m inflating the manual cuff, fingers still on the radial artery.  I watch as the dial creeps lower, lower, still not feeling the tell-tale pulse, then faintly it comes.  64 palp.  Not a good thing.  As I’m feeling I’m watching her chest rise and fall.  Shallow halting breaths.

“I think it’s time, call an RRT will ya!”  I holler out the door.

Merly’s back, dragging the Code Cart.  “Tell me what’s been happening,” I say as the overhead page goes out, “Rapid Response 5NW.”

“I don’t know.  I checked her at midnight and came back to check on her fluids and she wasn’t responding to me.”  Merly says as the code team starts to fill the room.  Furniture is disappearing out of the room as we make room for the extra bodies.

Fave ICU charge nurse is first in, “Hey Wanderer”  she says.  We’ve been through this before more times than I would like to count.  I look around, Merly has disappeared once again.  “Uh, 78 year old female, found unresponsive, BP 64 palp, pulse weak and thready, resps shallow…”

“Uh Wanderer, she’s agonal…”  Fave ICU nurse says, “Call a Code!” she hollers out the room.

I look over, Mrs. Smith is surely agonal breathing.  Erratic, shallow breaths separated by pauses that are far too long.  I kick the brakes off and pull the bed away from the wall.  Someone tosses me a BVM, I pull it out and crank the O2 up.  I’m looking for RT as they are just slightly territorial, but no one’s here yet.  Head tilt, good seal on the BVM while I start to bag,  hearing the code page go out in the background.  Now people are streaming in.  It seems that with RRTs they don’t go balls out, they move fast, but not like when you call a code.  RT arrives and offers to take over the airway which I gladly let them.  I’ve seen RTs fight each other over managing an airway and I know they would just run me over so I leave it to them.

The ICU residents have arrived and not surprisingly, Merly is gone.

Once again no one steps up to talk, NsNN stands silently in the corner, fixing up IV fluids so I jump in.  “Uh, yeah, 78 year old female, admitted toady with hypokalemia, failure-to-thrive, we found her unresponsive with a BP of 64 palp.  She then began agonal breathing and we called a code.”

Mrs. Smith is just laying there, not even fighting the bagging.  We get her on the code cart’s Lifepack, and the monitor comes up showing sinus tach in the 130s.

“Let’s get some labs, draw a rainbow.  Anyone know what her K was on admit?”  the resident starts giving orders.  We’re lucky tonight, Dr. And actually wants to go into critical care and has her act together.  “You guys think we need to tube her?” she asks the RTs bagging her.

“Yeah, she’s not even fighting us nor helping a bit.” one of them says.

“How about some fluids?” says the resident.

“NS up and wide open.”  says NsNN.

“Y’all need to leave her alone!”  I hear from the other side of the curtain.  Then I realize that her neighbor has been adding her own commentary to the proceedings.  “Hey NsNN, can you talk your patient down a bit?”  I ask knowing that we’re only starting to rile up her demented roommate.  The comments she has been making would be funny in any other situation, but not tonight.

“Do you guys want to tube her or should I?”  asks Fave ED doc as he enters the room.  “Go for it.” says Dr. And.  Fave ED Doc grabs some gloves, tosses his stethoscope in the corner and starts talking to a freaked out looking guy in  a short white coat that came with him.  “Normally I would let you try, but not right now.  I’ll show what we’re going to do though.”  A visible wave of relief spreads across the poor guy’s face.  Tubing someone is one thing, tubing some one in front of an audience of hundreds is another.

“Uh,”  he says looking down, feeling the throat and jaw, “How about a #3 Mac and a 6.5 tube.  Do we have drugs?”

“Yeah, here!”  pipes up the pharmacist standing by the door, just on the edge of the chaos.

“OK, she’s what 50 kilos?”

“40, soaking wet.”  I say.

“Right, let’s do 15 of etomidae and 40 of succs.  Suction ready?”

I’m standing at the IV site, guarding it like it was the last beer in my cooler against a thirsty horde.  The pharmacist hands me the bottles of meds and a couple of syringes.

“15 of etomidate, 40 of succs, right?”  I ask, just to make sure.  “Yeah.” comes the distracted reply.  He’s face down with the scope looking into Mrs. Smith’s mouth.  I glance over at Fave ICU Nurse and quietly ask, “Etomidate first, then succs, right?”  I ask, then add, “It’s been awhile.” to qualify my question.  She nods.

“Alright, every body ready?”  Fave ED Doc asks.  “Let’s do this.”

I push the first,  “15 of etomidate in…” flush it wait a breath and push the next, “40 of succs in.”

A brief moment of action and then “Got it…someone want to listen?”

Fave ICU nurse and I, plus about 3 others start putting scopes on.  “Equal bilaterally.” is consensus.

“Let’s get her packaged and downstairs to the Unit.”  says Fave ICU nurse, “I’m going down to let them now we’re on the way.

Sometime during the preceding 5 minutes Merly showed back up, carrying a handful of supplies, fluids, tubes, IV miscellany.  But at least she’s here.   Since the start we’ve had about the same for blood pressure, in spite of the fluids .  Her roommate is still muttering at us, telling us what to do and adding her own running commentary and answering questions along the way for her obtunded roommate.

Transferring a critical patient to the ICU is a exercise in logistics.  We have an RT at the head of the bed breathing for her, trailing along is the residents, the IV pole, Merly and assorted other folks.  And naturally the elevator that comes first is the small one.  We fit.  Barely.

We pull into the pod where she’s headed.  This time I managed not to drive by feel getting the bed into the room.  Thankfully Merly is here with us.  One of the ICU nurses pulls her aside for report.  We get Mrs. Smith over to her new bed.  40 kilos was a guess, but it was pretty damn close, she’s so light.  I gather up the stuff that goes back with me upstairs and look over.  They’re about to  turn her onto her side to pull out the extra detritus under her and she pukes.  She’s on her side quicker than one would think possible.  “Suction!”  someone yells.  I get a glimpse of the vomit.  It’s brown.  It looks like poop.  Then the smell hits me.  It is poop.  Really not good.

Knowing there is nothing else I can do I crib a page from Merly and disappear myself.  NsNN and I are pushing the bed back upstairs, musing over what we just saw.  “Merly and I are going to have a talk I think.”  I say.  “This isn’t the first time we’ve RRt’d or Coded one of her patients are she isn’t around.

“You did good though,” I say to NsNN.  “It’s like I’ve been trying to tell you:  you know what to do, you know the answer, but you just have to believe in yourself.”

“Thanks, I know, but it’s so easy when you’re around…”  she says back.

Back on the floor I start relating what transpired on the way there.  “That was fun wasn’t it?”  I asked sarcastically.  Then we all went back to what we were doing before.  Because that’s how it is.  We fix them enough for them to be someone else’s problem then go back to what we had been doing.  It’s hard.  You go over it in your mind, wondering what did we miss early on, did we do everything right, are they OK?  And even though it wasn’t my patient I muse if it had been.  She was where she needed to be.

I found out a week later when I came back to work that they took Mrs. Smith to emergent surgery the night we shipped her down.  On opening her they found a belly full of poop and a perforated bowel.  Evidently Mrs. Smith had undergone a gastric bypass-type surgery in the 70’s and they think her anastomosis had finally failed.  With a belly full of poop she went into severe septic shock and came out of surgery maxed out on pressors while they searched for any family.  Mrs. Smith had lived alone, we didn’t even know if she had family.  Through some digging and a little bit of luck they were able to find some.  She held on long enough for them to say it was OK to let her go.  And then she was gone.

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