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.

How to Scare a Tele Nurse

Or, “oh shit!  That VT isn’t stopping!”

I’m walking into the nurses station the other night when I hear the “oh shit!” alarm ringing in the tele cave.  Y’know the one, that incessant, high-pitched dinging that is saying “Pay attention!”  Reflexes trained by my years on a tele floor I look up expecting to see someone bradying down, or maybe some nasty artifact, but instead I see this starting – and it’s not stopping!

Do I…
A.) Start screaming like a little teeny-bopper freaking out and run in circles?
B.) Shit my pants?
C.) Drop what I’m doing and high-tail it to the room in question?

Believe it or not, C is the correct answer.  Sphincter slams shut as I haul ass down the hall.  I bust in the room expecting to find a dude laying there, unresponsive, not breathing or generally not doing well.  Instead I see dude and his nurse clamly chatting.  I breathlessly ask, “Were you shaking the leads?”

“No” she replies, “What’s up?

Dude looks up and says, “Is my heart racing again?”

“Uh, yeah, he’s in VT.”  I say, amazed that he’s sitting there calmly chatting.  “Do you feel funny or anything?”

“Yeah, my heart feels like it’s going pretty fast.  But I’m used to it, it’s happened many times before, no big thing.” he replies nonchalantly, basically amused with the gaping look on my face.

So we hook him up to the bedside monitor, and sure enough, there it is VT, rate in the 150’s, BP is 100/53, he’s pink (ok, kind of yellow), warm and dry.  No light-headedness, no dizziness, he does admit to a little bit of chest pain, but in reality he’s in better shape that half the floor, except that he’s in this particular rhythm.

Prehospital 12-Lead ECG has a great quote on their wide complex tachycardia page, “If it’s a wide complex rhythm (fast or slow) it’s ventricular until proven otherwise!”  And that’s how we were treating it.  So we grab some labs, call the ICU team to come assess him and a 12-lead EKG.  Should we have called a Rapid Response?  Maybe, but we felt we didn’t have to.  He was stable.  He has had this many times before.  And he was sitting there cracking jokes with us.

So here’s the 12-lead:

So what to do now?  The ACLS algorithm for tachycardia with pulses starts with determining if the patient is stable.  Check.  He’s cool.  Establish IV access.  PICC line left upper arm.  Check.  Wide or Narrow complex?  Duh.  Obtain 12-Lead EKG.  Check.  Expert consultation advised.  Check, ICU team is here now.  Amiodarone if ventricular tachycardia or unknown, adenosine if SVT with abberancy.  Oh, wait…he has a history of WPW and 3 failed ablations.  Now what?

This is where expert consultation is really a good idea.  In our case, he’s now cracking jokes with the ICU team as well.  He’s still rolling along between 145-160 BPM.  We grab some labs.  Turns out his potassium sucked, magnesium sucked and his calcium critically sucked.  The Team decides that amiodarone would be a good idea and getting his electrolytes sorted out might help as well.  So we’re hanging amio, mag and they’re calling cardiology.  Mind you this is 2130 on a Friday night.  Do you think a cardiologist is going to come in at that hour?  Nope.  She says, “Oh, just have one of the ED docs cardiovert him and call it good.”

He gets packaged and ready to roll to the ICU, ’cause by this time he was pretty much a 1:1 and the nurse had 3 other patients she was already neglecting.  Grab the defib off the code cart, because with our combined luck (this nurse and I have a history of codes/RRTs) dude will decide to stop having a pulse once we’re between floors in the elevator.

The rest is rather boring.  A little bolus of propofol (yeah, we MJ’d him good!) and the judicious application of 100 joules of DC electricity fixed him right good.  One shock and back into sinus.  But it was a good thing he was in the Unit as they spent all night getting his ‘lytes repleted.

What could have been a very bad thing ended up being a very, well, fun thing.  Too often on our floor a busy night consists of incontinence, wrangling demented patients back into bed 30 times an hour or chasing naked psych patients down the hall, so dealing with a true cardiac issue was a rather refreshing change of pace.

Observation Lovin’

Our observation unit is lovingly called the Hooper Annex (Hooper is our local detox unit) as not a day goes by that we don’t have at least 1 in with ETOH-related issues.  But we get dumped on, a lot.  Usually it’s because the docs can’t or won’t make up their mind and end up passing the buck.

Can’t figure out what to do with grandma, but there’s really nothing medically wrong with her?  Admit to obs.

Oh, you’re drunk and it’s cold outside?  Admit to obs.

Gastropareisis needing dilaudid?  Obs.

I know that an observation unit is a place to send the patient if they just a little too unsafe to send home, but not sick enough to be admitted.  And it can be a great thing.  Take for example uncomplicated chest pain.  No family history, no pain at rest, pain resolved PTA, but you’re male, age >50 and smoke.  OK, perfect obs admit.  Grab some serial enzymes, an EKG in the morning, maybe a stress test and off you go.  Or when your troponin I jumps to 5.0, we can start beta blockers, integrillin and call the cath lab.  Either way, we’ve done the right thing.

On the other hand you get a patient that needs a little IV antibiotics for an upper arm abscess.  The labs from their PCP are borderline icky, not enough to say definitively one way or the other if in-patient admission is warranted.  What to do?  Based on old labs, because why would we pull new ones, just plan to admit them to obs.  Then maybe grab a few new labs to direct therapy.

But if things had gone the right way, y’know like accurately triaging the patient, doing a complete workup before sending the patient out of the ED, like with labs and stuff, we wouldn’t be looking at this trainwreck patient rolling by the desk looking at each other going, “Uh, oh.”

If you had drawn labs first you would have been floored by the lactate of 2.2, the WBC >18, a H/H in the shitter, mult. 4+ accumulations of gram-positive baccili and cocci and gran-negative baccilli growing from the wound culture you just did the in ED or the raging case of rhabdomyolysis with a CPK of 96,000!  Yes, 96,000.

Luckily for you,we queried this lack of workup where you found all of these values.   We had a funny feeling, y’know that gut-level, spidey-sense feeling that this patient is not going to turn out well without a higher level of care.  Thankfully you ended up placing the patient in the ICU so they could run pressors and hang lots of lots of fluid on his septic self, instead of on observation where we would have had to rapid response them to get them to the unit as they crashed before our eyes.  Yeah, good call.

Be Careful What You Wish For | WhiteCoat’s Call Room

The nurse followed them into the room, pulled the curtains, and hooked the patient up to the monitor. Heart rate in the 40s. Blood pressure 120s systolic.

The tech was entering the patient’s information onto the computer when the nurse walked out of the room and told him “Hey. You got your wish. There’s a code.”

I looked up from the admission orders I was writing.

The tech got an excited look in his eye and says “Really?”

The nurse tossed him a washcloth and said “Yeah, really. Code Brown. Get wiping.”

via Be Careful What You Wish For | WhiteCoat’s Call Room.

Having been the cause (not literally) of 2 codes, first by saying the “q” word in a not-so busy ED one night, the second by saying, “We haven’t had a code in awhile have we?”  I have learned my lesson.  Pretty sure that the tech will have learned his!

Can’t Put it Into Words

We had a code the other night.  It was by far the “best” code I’ve ever been privy to.  No yelling orders, no standing around waiting, no egos, just a concerted effort to save a dying (well, dead) patient.  The resident running the code was calm, cool and collected.  As we did our interventions he worked through the H’s & T’s trying to figure out if we could fix anything.  Outside of my ACLS megacode, I’ve never seen that.  But moreso, he asked the staff if there was anything that we thought he had missed.  And before he called it, he aksed if anyone else had any objections.  Truly it was a team effort.

But for some reason I can’t seem to shake it off.  I had no real connection to the patient, other than being the charge nurse.  They weren’t one of our frequent flyers.  But something reached ahold of me and won’t seem to let go.

Maybe it was the fact we found her already down in her room.  Or the fact I felt the ribs snap under my palms.  Or it was that we did CPR on her for 30 minutes, rotating between 2, then three of us.  Or that we threw everything in the code cart at her, and some things that weren’t,  but nothing seemed to help.  Our CPR was some of the best I’ve ever seen/felt.  We shocked her a total of 9 times.  She got tubed incredibly quick.  But it didn’t seem to matter.

For the last couple of nights, I’ve laid awake and thought about it.  Re-running it over in my head, which then sparks memories of other codes and then to the memory of running in to see them performing CPR on my little girl.  For some reason, this one cracked my shell.  Like the title says, I can’t put words to the feeling.

Maybe though, it re-affirms that I am human and that I do care, something that I’ve been feeling a great distance from.  Maybe I’ve grown cold over it all- something my wife mentioned in passing not too long ago.  Maybe this nagging sense of malaise over this event is me re-examining myself over this coldness and cynicism and the realization that I’ve moved that direction has left me a little out of sorts.  More than anything though, it serves as a reality check, a visceral reminder of what we do as nurses when things do go south.

I know with time this angst and malaise over it will fade.  I’ll make peace with the way I feel about it, but like all the others, I’ll never forget.

Summer Medblog Smackdown

In booming announcer voice…

“Ladies and gentleman, boys and girls children of all ages…welcome to the Interwebs Arena for our main event of the  Summer…”

“Fighting out of the Doctor’s Corner wearing the red trunks, the contender from a big hospital somewhere in America.  With a record of 200,000 and 0, years and years of residency training, thousands of sidebar ads and an ego a mile wide, Happy “I’m a Medical Doctor and have my own way of running a code” Hospitalist! …”

“And out of the Nurse’s Corner, wearing the blue trunks, the challenger from a big ER somewhere else in America.  With a record of a million saves, years of being at the front lines of American health care, a chip on her shoulder and Dr. Bloody Gloves in her corner, Nurse “The Snarkinator, can’t believe Happy runs a Code like this” K! …..”

crowd goes wild…

“Let’s get ready to ruuuuuuuumble…..!”

referee…

“OK you two, let’s have a clean fight.  No low blows, no crayzee talk…oh whatever, just come out swinging.”

announcer

Happy and Nurse K are at it again.  Sit back and enjoy the show.

Not going to say who’s right, who’s wrong (although Nurse K is right dude, either wake the patient up for fucks sake, hello, sternal rub ’em! or pull the cord for the code team), but it sure is turning out to be a real smackdown.  I mean between Happy’s smug aloofness and K’s snark attack, you’ve got a real read on your hands.

Happy’s Post: Michael Jackson May Have Died From Fibromyalgia

Nurse K’s Rebuttal: How to resuscitate a patient Happy-style

Happy’s Attempt to hide the fact he got pwned: Is It Reasonable to Stock Every Room With Emergency Resuscitation Supplies

Would you two just get a room or something…

Edit: K just posted up a rebuttal to Happy’s rebuttal (a double butt-al?)  Face it bro, you’re getting pwned.  Throw the towel.