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.

Kind of weird

It’s kind of weird to see a co-worker looking at your blog while at work and having no clue that the author is sitting less than ten feet away.  Or at least they didn’t say anything about it..

Oh yeah, it looks like Mr. Black Cloud is back.

Why do patients try to die right before shift change?  Don’t they know the last thing I want to do before I go home is send them to the Unit.  Well, I wanted to send this guy to the Unit, he was Sick (notice capital S?).   But why at all times to crump than at 6am?  It must be my luck.

Making the Transition

Jerry had been on our floor for a little over a week, maybe a bit longer.  And he wasn’t getting any better.  In fact each day he seemed to get worse.  Small gains would be erased by further declines.  The anitbiotics weren’t doing their thing.  He was lucky to keep his O2 sats above 90% even on 10L high-flow nasal cannula.  It seemed like all he had to do was turn his head and he would de-sat into the low 80’s and take 10-20 minutes to come back up.

Unfortunately for Jerry his run with usual interstitial pneumonia was nearing its close.  His lungs were so scarred and fibrotic that there was nothing we as health-care providers do, except to place him on long-term ventilation, something which he had frequently and definitvely said he did not want.  One day he made his decision:  he was going to die,  Jerry wasn’t my patient, but I had interacted with him, albeit briefly, but understood from those interactions that this was a man who knew what he wanted to do and to continue living like this was not one of those.

I arrived at work the other night and the day charge nurse said to me, “We’re going to help Jerry die tonight.”

“What do you mean?”  I asked.

“He made the decision that he’s going to take off his oxygen and let nature take its course.” she said.  “But we’re going to make him comfortable and treat his symptoms.”  she finished.

“So everybody is on-board with this?  They’re not going to ry to change their minds half-way though?”  I asked.

“No.  The family is here, they’re in the process of saying good-bye.  Even his doc, who came out of the room crying today after he made his decision, is behind him.  I think everyone knows what he wants and are accepting that.  To help with that though I did staff you up a nurse.”  she said trying to put a spin on it.

I was still processing the idea.  I know that we’ve had comfort care patients who we let slip away, but never had someone who was completely lucid and in control of their faculties tell us to let them die and for us to actively help him make the journey.  In a strange way I was almost proud, can’t really find a word that describes how I felt, of Jerry for actively deciding how he was going to end his battle.  Instead lingering in an ICU, hooked up to a ventilator with nearly no quaility of life, he decided to take matters into his own hands and say, “This is how, this is when it is going to happen.  Finally, I’m in control.”

The nurse who had taken care of Jarry for the previous couple of nights was back again.  I hoped that she would be willing to take this on, but I knew she wouldn’t refuse, even if she was ucomfortable.  I saw her as she left the locker room and pulled her aside.

“I have to talk to you about tonight.  Jerry is planning on dying tonight.  I thought since you have a relationship with him, having taken care of him for the last couple of nights, you should get the assignment.  He’ll be your only patient and I’ll be your back-up and runner.  But, you have every right to refuse this.  I can’t force you to take this on.”  I siad as I laid out the situation.

“No, I can do it.” she replied.  “We don’t have that great relationship, it’s not like we’re friends, but you’re right, he knows me, is comfortable with me and I think that would be most appropriate.  Besides who else would step in?”

“Me.” I said.

“No, I’ll do it, what is going to happen?” she asked.

“Basically he’s going to let you know when to take his oxygen off and let things go from there.  You have medication orders for anxiety and dyspnea, so you can keep him comfortable and peaceful.”  I said.

We went off to start the shift and get things going.  She came up to me a little later and said, “I just talked to the doc who is covering tonight and he explained everything to me.  He even asked me if I wanted him to stay…it was a little surreal.  He did give me his pager and said if I wanted help, or needed support, he’d be willing to even come in to help.  Right now family is in saying their good-byes.  I’ll let you know when we decide to start.”

A little later she started.  She spent hours at his bedside, sitting with family and him reminiscing, learning about Jerry as he slowly started to slip away.  She would turn down his oxygen, give him some meds and wait for awhile and do it again.  About 1am she came out to both reload and take a break.  She said, “He’s hanging on.  He’s kind of Cheyne-Stoke-ing, real shallow, so when his family slipped out awhile ago I checked some vitals, he was 50/30, sats of 35%.  The doc had said it would be fairly quick, but I guess he’s hanging on for something.  I feel like there’s something else I should be doing. I mean, I’ve never done this before.  Is there something I’m missing?”

“I don’t think so.” I said.  “Maybe he’s not quite ready to let go.  Maybe give him anothe dose and let him sit with his family alone for awhile.”

And that’s what she ended up doing.  He had started to gasp a little so she gave him a dose and then left the room.  Sure enough about ten minutes later she went in to check and the family told her he was gone.  Normally we call the houe docs right away to pronounce, but with family at the bedside I decided to give them some time.  In the end we called the doc, who was a bit perplexed about why we called him, even more so why Jerry had decided to do this, but came and did his part in the end.  As part of protocol I called the attending who had told us o call if we needed anything to inform him and he asked how it went and if he was comfortable to the end.  He cared enough about Jerry to give him the dignified death he deserved and make sure it wasn’t a traumatic death  and he did a good job.

Helping Jerry make the transition was strange.  So often we’re going for the opposite, even when people are at the end we try to prolong life as much as we can.  But Jerry didn’t want that.  He didn’t want to live out the rest of his days on a vent, with lines and tubes coming out of him.  He chose how he wanted to go.  And that’s so rare.

Blackcloud’s back. Maybe.

I knew the streak had to come to an end.  The lack of code/RRT streak that is.  It’s ben since the 13th of June since I was involved in such a situation.  That really is a whole bunch of charge shifts too, by the way.  And nothing, nada, zilch.  Until tonight.  Respiratory distress, leading to a bed in the Unit.  I’m hoping Blackcloud was just in for a visit, nothing permanent.

We’ll see.

Happy Ending?

No.  Not that kind.  But a happy ending to a code.  It’s rare.  I’ve seen it now only twice (and a third may be underway, but that’s for another post).  Most of the Codes we have on the floor do not end well.  It either ends in the patient being pronounced on the floor, or later on that night, or sometimes week in the Unit.  Our Rapid Responses seem to have better outcomes, but then again, folks usually aren’t dead when we call a RRT.

The other night was going along as planned.  Assessments and vitals, med and insulin being handed out like candy when I walk out into the station from the med room.  You could tell something was afoot, there was just a buzz, almost an anticipatory buzz that something might happen.  Hoping not, but sometimes you just know something bad was coming.  We knew one of our co-workers had a patient who was starting to decompensate, badly, but was still stable.  I had run into her in the med room about an hour back and learned what was up, but she was holding her own.  John, as I’ll call him, had been admitted for pulmonary edema, spent a night in the Unit and come up to us in the afternoon.  He was going for an angio the next day, but was becoming increasingly short of breath, and his BP was way up, like 190’s over 100’s.  So I decide to go check on her.  Sometimes just having someone pop their head in to check on you when you’re in a situation can be stressful (see the landing scene in Airplane), but in others, it’s comforting to know you’re not alone.

I get in the room and look over at John.  He does not look good.  He’s sitting up at the side of the bed, in a semi-tripod sort of position, non-rebreather mask on, and working pretty hard.  I glance down at the portable pulse oximeter on the bed beside him; it reads 78%.  On 15L NRB.  Not good.  Angie, the nurse looks at me, “Let’s get him back into bed, see if we can get him breathing better.”

We move him back, but as we’re getting him settled, he lolls his head back.  “Shit!”  I think.  “I’m going for the cart, you might want to call an RRT”  I say as I dash out the room.  Luckily, John’s doc is still at the station, as I blow past him, “You really need to go see John, he’s crashing quick!”

Down the hall as I hear the clarion call of the overhead calling out for an RRT.  I look at the other nurse’s station and make eye contact with my charge nurse and say, “You might want to join us, we’re having a little fun down here!”  Totally calm, totally collected.  Her jaw drops, but I’m already down the hallway with the cart.  Twenty feet down I hear a Code being called overhead and see the unit secretary gesturing violently to “get my ass down here, now!”

The other staff are pulling furniture and family out of the room as I run the cart inside.  The doc is at the bedside as we hook John up to the monitor.  We’ve got a pulse, but his beating is getting worse, more wet, more ragged and he’s working very, very hard.  By now the room is filling up with people; RT, ICU nurses, our charge, dietary, other nurses, housekeeping and a couple of residents.  Break the cart open to grab airway supplies.  The doc calls for a Mac 3, which I hand over to him.  Funny thing, I only worked in the ER as a student for 3 weeks, but knew exactly what to hand him and even checked to see if the light was working, almost by reflex, weird.

He tries to intubate, but no joy, tube’s in the stomach.  He calls out, “Can I get some roc (rocuronium, a paralytic)?”   Someone else pipes up, “Don’t you want some sedation first?”  John is bucking now, he was fighting the tube on the first pass and now his pressure is through the roof, 220’s over 120’s, but with a strong pulse and good rhythm, his body is just in survival mode.   Dude was a rock.  The rest of the room was pretty much chaos.  Pharmacy didn’t have Versed with them, so it had to be raided out of Pyxis.  The portable suction machine was about to die.  RT is trying to maintain a patent airway and bag John.  Calamity.  Then anesthesia steps up ad takes over.  Like a captain of a foundering ship, he takes control.  It was intense to see.  Totally cool, calm and collected, he starts giving orders.

He asks for vitals.  The ICU nurses can’t seem to figure out how to cycle the automatic BP cuff and are getting increasingly flustered.  I can’t do it, I’m guarding the only site of access available at the moment.  I look over and my buddy Ken is next to me, contorted taking a manual blood pressure.  He’s tucked under my arm, craning his neck to see the dial on the wall behind anesthesia, and in spite of everything, gets it.  We push nitro and labetalol to bring down his pressures, then Versed to knock him out and now, some rocuronium to paralyze him.  I’m juggling syringes and flushes, wishing I had an extra hand, but somehow keeping them straight.

Now sedated and paralyzed, he gets intubated. But when the stylus is pulled out, a stream of pink frothy liquid comes shooting out of the ET tube.  Massive flash pulmonary edema.  The look on anesthesia’s face is priceless: a mix of awe, wonder and sheer terror, as he had been in the line of fire seconds before.  More meds, start running a nitro drip and we get John packaged for transport.  RT is bagging John sporting the oh-so fashionable face mask provided to them to protect from flying froth.  And off to the ICU we go.

We get John settled into his new bed in the ICU and one of the ICU nurses, who had previously been, well, freaking out, looked over and said, “You guys did a great job up there.”

“Thanks,” I said as I grabbed the bed and our transport monitor along with the other little bits we needed to return and headed back upstairs. Waiting for the elevator I feel the adrenaline slowly staring to fade and the post-rush shakes starting.  When I get back upstairs, anesthesia is still there writing his note, looks up and says, “You guys did a great job in there.”  Wow, twice in five minutes, I guess our floor does have it together.  Talking about it later with Ken, he says, “Y’know, we (our floor’s nurses) were the only cool heads in that room.  You totally calm, it was awesome.”

Fast forward a week.

I figured John had been in pretty bad shape.  I wasn’t expecting to see him sitting in bed as I walked into one of my rooms to introduce myself as his nurse for the night thought.  I said, “You look a heck of a lot better than the last time I saw you!”

“I’m sure” he replied, “But I really don’t remember all that much about it.  Just glad I came out of it OK.”

Well they had done the angio and found he had severe triple vessel disease only correctable through bypass and was schedule for surgery in the morning.  I made sure I spent a little extra time with him that night, just making sure he was comfortable and ready to roll.  He was up bright and early to get prepped for surgery, and for once I didn’t forget to do anything off the checklists. I wished him luck as he slid over to the gurney on his way to the OR and said, “I’ll see you when you get back up here.”

And you know what?  He sailed through surgery and recovery like a champ.  Last I saw him, the day before discharge, he was up, walking around, weak, but doing well.  He ended up going home the very next day.  Like I said, a happy ending.

A Revisit to Room #66

As I related in a previous post (here), room #66 and I have a storied history. Some of it good, some of it bad. I finally figured out the mojo that was haunting me: it was the particular charge nurse. Each and every time I have had an issue in room 66 it was one particular charge nurse. Didn’t have a problem with that room when other charge nurses were on. It was her. Not that she is a bad person, or even a bad charge nurse, there is just some weird mojo about it. Superstitious? You better believe it. And I’m not the only one. Nurse Sean has shared his superstitions. Do I have some? Yes. But that’s not the point.

How did I figure all of this out? Stick around, you’ll see.

A couple of months ago, my assignment included room 66. Housed there was one of our frequent flyers. Atypical chest pain, responded only to morphine. Chronic shortness of breath. On top of all of that he was a smoker. Loved to leave the floor to smoke. For two nights I had him with another charge nurse. Yeah, there were a couple of hairy moments. But nothing a little morphine and a neb treatment couldn’t fix. But then the charge nurse rotation happened and you know who was in charge.

At first, the night went like normal. Nightly nursing things done. Meds were passed. Mr. Chest Pain was doing just fine. He had even gone down to smoke twice and never had a problem. I had everyone except him tucked in. I had even charted my first set of nightly charting before midnight – which never happens. The call light rings for room 66. The aide comes up to me and says, “He can’t breathe and is complaining of chest pain.” Down the hall I go. I peek in. He’s tachypneic, distressed but not too bad. I head down to the med room, call RT on the way and grab a touch of morphine to both calm him down and help him breathe until the neb got there.

By the time I got back to to the room however, things had changed. He was bolt upright in bed, using every muscle in his torso to breathe. I swear he was rocking his hips to help him breathe. For a second I sat there, transfixed by what was happening before my eyes. Then I grabbed the phone, “Rapid response to room 66, rapid response to room 66!”

I began hooking him up, grabbing a set of vitals when help began streaming into the room. The doc took charge as I gave him a run down of the situation. Shot a CXR, took a 12 lead, and he got a double strength neb. After a bit of time, he began breathing better, calming down a bit. Of course first thing out of the RT’s mouth was, “When was the last time he went to smoke?” Lucky for me he hadn’t been down since 8pm (and it was 2am). Soon he was breathing better. No longer straining, no longer using every muscle to breathe.

As the crew left, we sat and talked. He had a bit of a wide-eyed look to him. As we talked re told me how scared he had been, especially when all the people began flooding into the room. Of course I couldn’t share how scared I had been. He told me the thought in his mind was, “Please don’t tube me!” He told me he had been tubed before and it had been the worst experience of his life. Then he said, “I think I may go for a smoke…” To which I said, “Y’know, I really don’t think that’s a good idea right now, do you?” Grudgingly he agreed, then settled in and went to bed.

When I walked out my charge nurse met me in the hallway. She said, “They never said which room, but I knew. I knew it had to be 66.” “Yep, ” I replied “it’s my room, but I really think it’s you. Things seem to go well when you’re not charge and I have it, but when you’re charge…”

Since then she’s tried not to give me 66 when she’s charge. At least I learned a lot since then though. I looked back at the situation and know what I should have done differently and if presented with a similar situation, would probably do better and probably wouldn’t have called an RRT. Oh yeah, and Mr. Chest Pain? Yeah, he went down to smoke no less than 3 hours after the commotion. I guess some people never seem to get the point.