His normal mood is quite sour. Typically indifferent. He’s not chatty, never cracks a smile, never jokes around. All you normally get out of him are softly-spoken and terse, hard to understand answers.

That day he agreed that the prognosis was probably hopeless. When I called with an update on her deteriorating condition, he said he wasn’t surprised but that he’d be in to see her. He was there within 15 minutes. His mood was elevated to what most people would describe as ambivalent. He seemed almost chatty. More willing to explain things. I was surprised.

During the procedure, his cell phone rang with what sounded like an annoying pop song. His eyes, usually partly cloudy, became dark and stormy. One of us was holding her still, the other was sterile. He fixed his troubled gaze at the one remaining nurse in the room and said, “Can you get that?”

Not an unusual request.

The nurse lifted up his scrub top a little to find the cell phone clipped to his waistband. She had some trouble getting the phone off the holder, and before she could answer it, he said,

Ask her what the hell she’s thinking calling me right now.

Ask her what could possibly possess her to bother me at this moment.

Ask her!

The nurse and I involuntarily glanced at each other. What the…?

She opened the phone and said,

“Hello?”

“Um… he’s busy right now… can he…”

“TELL HER I’LL CALL HER BACK WHEN I AM DAMN GOOD AND READY! TELL HER SHE’S AN IDIOT FOR EVEN THINKING THAT I COULD STOP WHAT I AM DOING TO TALK TO HER AT THIS POINT IN TIME!”

“Um… did you hear… ? Ok… Bye.”

“What did she say?”

The nurse and I exchanged glances once again. This did not go unnoticed.

“Nothing. She said nothing.”

Turning towards the nurse that was sterile, his eyes starting to clear from hurricane to mere tropical storm, he said, “I need the drill now.”

And that was that.

I was out at the desk putting more paper in the recorder when a patient’s wife came running out to the station.

“Please come quick! Someone come check on my husband!”

Not having heard any alarms, I quickly glanced at the monitor and saw nothing out of the ordinary (Not like that comforts me any more) but headed into his room right behind his wife.

“He’s breathing fast, he’s coughing and his pulse is really high!”

I looked at the patient. He was on the ventilator and yes, he looked as though he was breathing a bit fast. The vent confirmed this, showing that he was breathing over 40 times per minute. Looking at the monitor, I saw that his heart rate was 88. I then turned towards the wife and she knew what I was going to say…

“Well, it was 102 a second ago!!”

“But it’s okay now. And you’re right, he’s breathing fast. This is the second day that we’ve tried to wean him from the ventilator and he’s not tolerating the lower settings. His nurse is in with her other patient; I’ll go let her know.”

Her shoulders relaxed almost imperceptibly, but then tensed up again as she looked back at him lying in the bed. She started wringing her hands and talking defensively. “I don’t usually panic like this, it really does take a lot to…”

I put my hand on her shoulder as I interrupted her.

“But he’s your husband.”

I don’t know what she was expecting me to say, but it wasn’t that. Her face showed a split-second of surprise before her shoulders relaxed entirely. I don’t know how to describe it except to say that every feature of her face soon followed in a display of utter and complete relief.

“Yes,” she nodded. “He’s my husband. Thank you for saying that.”

Sometimes we take care of the families, too.

I’d just come on shift and was getting report from the day nurse. The patient had had a temporary pacemaker removed earlier that day. This is a wire that’s threaded up through a catheter in the femoral vein to the heart and is hooked to a pacer box. It’s a stopgap measure until the patient can have a permanent pacemaker put in surgically, or until the cause of the patient’s heart problem is fixed.

She was sitting up in bed eating a late lunch. Her family was with her, surrounding the bed. Family members get a look about them when a patient has turned the corner in a good way. It’s as though they’re still on edge, but also bathed in relief. Her family looked this way.

Before we even finished report, though, one of the family members came out and said that the patient was feeling nauseated. From eating hospital food? That’s a stretch! I briefly looked at her EKG on the monitor and wasn’t alarmed. I told the family member who I was and that I would be in there shortly to see the patient.

I went in there much sooner than I had expected to.

While getting report on my second patient, my first patient’s alarm went off. She was becoming tachycardic. I figured that it was due to the nausea making her anxious. I decided to check her on real quick before finishing report on the second patient. I found her looking basically okay, but definitely anxious. I asked her if she was still nauseated. She said yes and I leaned out of the doorway to ask the off-going nurse if she could get me an antiemetic. I took the patient’s blood pressure and it was a little lower than I liked. Low BP could definitely explain the nausea and tachycardia… but why the low BP?

I checked her groin site, thinking that maybe the clot dislodged from her vein where they took the pacer catheter out. If she were bleeding, it would cause her BP to drop. The site was soft and non-tender… no sign of bleeding. That didn’t mean she wasn’t bleeding retroperitoneally, though. I had the charge nurse page the cardiologist.

I removed the tray table and put the patient’s head of bed flat. I was only the tiniest bit worried – I figured we’d give her some fluid, send her for an abdominal CT to check for bleeding, and go from there. This sort of thing doesn’t happen often, but it does happen enough that I knew what to expect.

My patient started vomiting. Vomiting is hard to do (not to mention dangerous!) when you’re laying flat, so I helped her to her side to prevent aspiration. I rechecked her blood pressure and it was even lower; her heart rate climbing higher. I calmly asked the charge nurse to page the cardiologist overhead and call her office to have them page her directly.

By now, of course, the family had completely lost their glow of relief. The patient could tell by my repeated request for the doctor that something wasn’t right. I briefly explained what I was thinking (possible bleeding = low BP = high heart rate = nausea/vomiting) and they all seemed somewhat pacified for the moment.

It was a short-lived moment for all of us.

My patient’s oxygen saturation started falling. My worry-meter was slowly climbing. Maybe she ended up aspirating after all. We put some oxygen on her, but not before she vomited everywhere again – it ended up on her sheets, in her hair, on her gown. It wasn’t the most pleasant smell, and her nose was pretty much right in it. I tried to cover most of it with a towel. Right before I put the oxygen mask on her, she grabbed my wrist. I looked at her and she asked very earnestly:

“Am I going to die?”

And I looked her straight in the eye and said: “No.”

“It’s clear that you’ve had a setback here, but we are going to figure out what’s wrong and will fix it. We’re trying to contact the cardiologist now.” (WHERE THE HELL IS THE CARDIOLOGIST????)

It’s a long-standing truism in healthcare that when patients think they’re going to die, they usually die. However, that thought didn’t even so much as cross my mind, because I was too busy thinking that whatever was wrong with her was a Fixable Problem, and it was happening in a hospital in the ICU where there was lots of support and equipment and where We Saved Lives all the time.

I asked someone again to get ahold of the cardiologist any way they knew how, someone started a fluid bolus, someone started trying to clean the vomit up a little, and I… well I took a few seconds to take everything in, to make sure I wasn’t missing something.

And then she coded. V tach. No pulse.

Usher family out, get crash cart in, start CPR, hook up defib pads, someone’s bagging her and within a minute we shock her. No change. Times three. Ok – meds (Where. The hell. Is the cardiologist???), CPR, ER doc is here to intubate, I give him a quick rundown of the situation. Someone flings my carefully placed towels out of the way; now there’s all the vomit again, still on her gown, still in her hair and my denial regarding this Fixable Problem is finally shattered.

By then, someone has overhead paged any cardiologist to CCU stat and one shows up…. and right behind him is the patient’s cardiologist. FINALLY. She asks for someone to come up and do a stat echocardiogram and there happens to be an ultrasound tech a few rooms down that we seize. After a second of viewing the screen, the cardiologist sizes up the situation and asks for a 60cc syringe with a needle and before I know it, she has plunged this needle into my patient’s chest and blood, all this thick dark blood, starts coming back.

My patient had cardiac tamponade. The sac around her heart had filled with blood and her heart was unable to fill and squeeze due to the compression. We regained a rhythm on the EKG monitor, but we did not regain a pulse.

My patient, the one I had confidently assured not 15 minutes before, died. My naivety died with her.

I didn’t know. When she asked her last question, I had been 100% positive that she was going to be just fine. I don’t really fault myself for not knowing anymore, but I do regret that the last person she spoke to was me, and not her family. I regret that she died with vomit in her hair.

I regret that I did not at least entertain the notion that I was wrong.

Sweet Mother of Mary.

When I decided to update my links over there off to the right, I did not realize that I would be adding sixteen more nurse blogs. Nurse blogs have really taken off! I couldn’t be happier – the more people that can read about what nursing is really like, the better. And the chance to get to know other specialties (ER nursing, Psych nursing, Labor & Delivery… the list goes on…) without actually having to float to them is intensely interesting to me. I started this blog over 4 years ago (December 2002!) and at the time, I found several doctor blogs, but only one other blog written by a nurse. Now there are so many, it’s hard to keep up with them. My sidebar has a sprinkling of the ones I read most often, but there are many, many, many more to discover here.

Anyway, I recently went back to work after 5 months off. It was a nice break, but I was ready to go back. One of my patients was a very sweet elderly man and the other was a very funny elderly man. My two favorite flavors! They were relatively easy but I soon found myself “in the weeds.”

Here’s why.

All shifts are busy on any unit, and I have worked all shifts, but flame me if you like – day shift, in my experience, is usually the busiest. There are daily labs to address, most procedures are done on days, most tests (CT’s, ultrasounds) are done, docs are making their daily rounds (which means they’re changing orders), and there are all of the daily meds to give.

Let me tell you something about the “give once daily” meds. 99% of them are scheduled for 8 or 9am. And some of our patients are on a lot of medications. Do you know how long it takes to give 10-15 pills to a patient who can only take them one … at … a … time? It can take awhile.

I’m used to this, of course. I’m pretty good at time management. But all the old frustrations came flooding back when I couldn’t get my patient’s EKG tracing to pick up. Fixing equipment is my #1 frustration. I hate when gadgets don’t work right. My job is difficult enough without having to take forever to troubleshoot and replace faulty equipment. I tried giving all the electrodes a little turn… sometimes that makes the tracing better and can at least pinpoint the EKG patch that’s not picking up. The tracing wasn’t affected at all. So then I went about changing all of the patches, which involved me having to take the old ones off (not even 24 hours old) of unshaved skin. Either it was an emergency, or the person who applied them is a sadist.

Meanwhile, the patient’s doctors are rounding on him and I don’t feel that it’s very nice to be putzing around under a patient’s gown while they’re trying to talk to their doctor – the one who only comes ’round once a day. I finally got all the electrode patches changed (having shaved parts of his chest so that when they came off they wouldn’t cause so much pain). Didn’t change the tracing AT ALL.

The mental commentary of the list of things I needed to get done was becoming increasingly louder, which added to my frustration level.

Finally I decided to just change the EKG cable. Of course, to do this, I had to hunt down a cable to replace it with. I don’t take cables from other rooms because who wants to go to admit a patient and find that they’re missing an EKG cable? I finally found a cable and had to go through the whole process of untangling the wires, rehooking the patient up, etc, etc. Bingo – perfect tracing. Which is all well and good, I’m glad it worked, but faulty cables seem to be appearing more and more. The really frustrating thing? For kicks, I decided to see how long his tracing had been virtually unreadable, and found that it had been like that long before I came on shift. Argh.

And then there was the old “Insufficient quantity of this medication currently loaded” on the pyxis. Even though Mr. Pyxis is supposed to alert the pharmacy when it gets low so someone will come fill it. Bah, who knows… maybe it had run out 5 minutes before, maybe 5 hours. Maybe they hadn’t had a chance to fill it yet, and I understand that… but again, it just adds more work for me when I have to send pharmacy a message and keep checking for the med.

They’re small little things, but they can really add up over the course of a shift. Is it like this everywhere?

I recently went back to work after having 4 really wonderful months with the cutest kid (go on, click it!) on earth. (This kid is a close 2nd!). It was nice to be back, despite the usual frustrations (of which I may blog about at a later date).

I had been encouraging my post-op patient to cough and deep breathe all shift. Although we like to get most surgical patients out of bed the next day to promote mobility and prevent pneumonia, my patient (for reasons I will not get into) was not able to be out of bed, even 3 days after surgery. Thus, coughing and taking deep breaths was extra important.

He was not the picture of health to begin with: rather serious lung problems, still smoking, diabetic, overweight, heart diseased and now rather immobile, he was a ticking time bomb for complications. Despite this, or maybe because of it, he was not really cooperative with the idea of having to exercise his lungs. He tried at first, but was understandably cautious due to the fact that his breastbone had been wrenched open and then wired back together. I get this, I really do. I provided ample pain medication, a pillow to splint with, and reassurance. And yet all I was getting was “eh eh eh” instead of “COUGH COUGH COUGH.”

I had a busy assignment and that, coupled with being a bit rusty (read: totally unorganized), meant that I was not able to spend as much time as I would have liked in this patient’s room encouraging him to cough. And I tend to be more of a gentle encourager rather than a forceful one. Alas, towards the end of my shift, he was requiring more oxygen and was feeling a little short of breath.

I was discussing this with some other nurses, and one of them brought up an interesting point. Maybe the patient was requiring too much encouragement from me to do what he needed to do to recover from major surgery. He “signed on” for this surgery and all it entailed, after all. At what point does the nurse’s responsibility end and the patient’s begin?

Over the years, my patients have run the whole spectrum of compliance and willingness to take part in their own recoveries. Some are fabulous. I think I’m so used to having to “make” patients do their incentive spirometers that I sometimes find myself wondering “what is that noise coming from my patient’s room?”… only to find out that the patient has actually heeded my advice and is doing it all by themselves! Some are completely helpless (although technically competent) and require massive amounts of encouragement, pep talks and scare tactics to do what they need to do to prevent complications. Some nurses are very gentle about this, and some aren’t. I’ll spend countless minutes explaining why the patient needs to get out of bed and convincing them to do so while some of my counterparts have the patient’s legs dangling off the side of the bed before the patient can so much as protest. Maybe I’m too caught up in the idea of patient autonomy. It makes me feel bad to “make” a patient do something, even if it’s for their own good. I guess it’s a form of tough love. Like parents to their children, nurses are not meant to be their patient’s friend.

Of course, a better outcome is preferable to making nice with the patients, even if the nurse comes off looking like the bad cop. (Actually I have used that tactic before. I’ve come into the room with one of the forceful encouragers and we good cop/bad cop the patient – my colleague helping me physically get the patient out of bed as I crone soothing words of encouragement while they insist that they aren’t ready to get up yet. It works rather well.) After giving birth to my son, getting out of bed the next day was the absolute last thing I wanted to do. I was exhausted. Everything hurt. My nurse flew into my room first thing in the morning and in no uncertain terms told me that I would be getting up shortly. She took my vitals and then said that it was time to get out of bed. I think it’s hard to convey the manner in which she did this, but it was definitely in more of a “bad cop” sort of way. She did everything as though she was mentally ticking off tasks in her head and was anxious to get to the next one. There was absolutely no reassurance or easing into moving with this new body of mine… it was just “get up, get going, and do it now!”

I don’t think it was necessary to be that aggressive. I wasn’t refusing to get up. I didn’t even verbalize my hesitation – she didn’t really give me time. Maybe that’s what bothered me. She acted uninterested in the notion that I might be uncomfortable and want to take my time. If I’d been less tired and more focused, I would have told her in no uncertain terms that I would be getting up, but that I’d be doing it as slowly as I darn well pleased. Instead, my frame of mind prevented me from sticking up for myself and I just did what she told me. I know that there are times when I’ve acted this way towards patients, but I always reserve it for the really super-stubborn ones. And always after I’ve expressed that I understand they are afraid. So would I have gotten up if I’d had a more patient nurse? Of course, and I probably would have felt more supported. Maybe patients try to stall and my nurse learned to head us off at the pass. She did not endear herself to me, however. But maybe this story doesn’t even belong in this post – her demeanor did not prevent any complications for me personally. Maybe I just needed to get it off my chest :-)

Everything turned out okay for my patient. His family came in, I explained the importance of breathing exercises and they badgered him relentlessly into doing them. I wonder if anyone’s done a study on outcomes for patients that have families who participate as opposed to families who are more hands-off. I truly believe that without his family, he would have not been able to be cajoled into cooperating with my plan to prevent pneumonia. After all, he did sign up for the surgery. I believe that it does ultimately come down to the patient, as long as they’ve been sufficiently educated about how to participate in their own recovery.

About a month ago, Flea wrote about some of the vaccine preventable diseases and what actually happens when one contracts polio, diptheria and tetanus. I had no idea what diptheria was before I read that post, but tetanus is a disease I have some experience with.

I’ve personally taken care of two tetanus patients within the last few years. One was an IV drug user in his 30′s and contracted it through one of the many abscesses he had on his arms and legs. He went downhill fairly quickly and was intubated and put on a ventilator. Usually when a patient is intubated on a vent, we give them about 2 weeks to get off the vent before we start talking about a tracheostomy. Tetanus patients, I learned, get trached and peg’d after only a few days. It’s understood that they are going to have a rocky course of illness and a very long recovery time and will have these procedures done sooner or later.

Tetanus is treated with antibiotics, anti-seizure meds and “supportive care.” This means life support, intravenous or tube feeding, etc. It’s intended to support a person’s vital life functions while the patient fights off the disease. Tetanus is also treated with muscle relaxers, but in this guy’s case, those weren’t controlling his extreme muscle spasms. He was already in a “medically-induced” coma, meaning that we were sedating the heck out of him, so the only other option we had was chemically paralyzing him.

Paralyzing patients is a balancing act. Too much paralytic can affect a patient’s heart rate (too fast, irregular) and cause them to spike high fevers. Not enough and you’re stuck with the muscle spasms and unstable blood pressures. To determine if we are giving the correct dose, we use a “peripheral nerve stimulator.” We put electrodes on the patients’ wrist (thumb side) or along their temple. We then hook up this little box that sends electrical impulses. We set it to give 4 pulses at varying strengths. The doctor determines how deep he wants the patient. If the patient is not paralyzed enough, you’ll get 4 muscle twitches at the eyebrow or thumb in time with the 4 pulses. If they are too paralyzed, you get no muscle twitches. We usually aim for 2 twitches out of 4 pulses at a moderate strength.

The other tetanus patient I took care of was in his 70′s and was a carpenter. He actually acquired a big splinter in his arm, which was the supposed mode of entry. He came in with muscle stiffness but was talking and awake when he got to CCU. Within 24 hours, he was intubated on a vent due to respiratory distress and 24 hours after that he was trached and peg’d.

He was one of the most difficult patients I’ve ever taken care of.

This man’s hemodynamics defined instability. In Flea’s post about tetanus, he states, “The slightest stimulation can trigger muscle spasms: the ringing of a cell phone, the flash of a digital camera, or someone in the room burping.” That isn’t an exaggeration. It was very difficult to titrate the paralytics for this patient, even with the nerve stimulator. I’d check his twitches at a dose and find the dose adequate; an hour later I’d check again and find that the dose was way off in one way or the other.

Literally the slightest stimulation – conversation in the room, barely brushing the sheet that was covering him, an IV pump beeping – would send his muscles into tight tight knots. One could literally see them tensing. In addition to this, his blood pressure would skyrocket!! One moment he’d be at 80′s/40′s and you could literally watch it rise to 240/130 in a matter of seconds. It would stay there until it was dealt with, which meant giving boluses of paralytic or sedation (Propofol, the drug we use for sedation, will cause transient hypotension when given as a bolus). If given too little of whatever drug I decided to play with, he’d stay well over 200/100, but if given too much, he’d drop to 60/30. The difference between “too much” and “too little” was so negligible. If I actually managed to find the sweet spot dosage-wise one time, that same dose wouldn’t work the next time. It got to the point where one nurse would have to bolus with paralytic or Propofol to ease the muscle tension while another was simultaneously titrating the Dopamine (a vasopressor) to prevent hypotension.

By the end of a 12 hour shift with that patient, I felt like my muscles were afflicted with tetanus. I was that high-strung afterwards.

Eventually, the wide swings in blood pressure abated and sneezing in the patient’s room no longer elicited a body-wide charley horse. This last patient was eventually weaned from the sedation, paralytic and ventilator. A few months after he was transferred out of our unit, we asked one of the social workers how he ended up. I’m happy to say that he made a full recovery and was able to walk out of the hospital after a lot of physical therapy.

I like the happy endings.

I know I’ve written before about futile care and about keeping people alive past the time when they should have passed from this world. News flash: I’m going to write about it again. Right now.

When I first began nursing in an ICU, I was very naive. I remember one of my very first long-term patients. He was having a second heart bypass surgery. Or maybe it was his third. I remember thinking, “Just how many times can one have bypass surgery in one’s life?” Well, in this guy’s case – three.

The surgeons and perfusionist could not get him off of the heart-lung bypass machine after the surgery. He just didn’t tolerate it. This necessitated them bringing the patient over to CVICU while still on it. Then it apparently turns into a VAD – a “ventricular assist device.” The hope was that it would take some of the strain off of the ventricle so that it could rest and then we could wean him off the machine over a day or so instead of over a few minutes.

I remember how busy he was and how complex it all looked. He was truly the sickest individual I had ever seen.

Call it blind naive optimism or too many TV medical shows, but …

It never crossed my mind that he would not recover from this.

He remained on the VAD for a few days or so. When he came off the VAD, he still required multiple pressors. He was swollen, sedated, and still the sickest person I had ever seen. He then followed a course that I was to witness many, many more times over my career: trach, PEG, weeks and weeks in the ICU, and once he finally left ICU he would come back several times before finally dying.

One thing I remember about him was that we would feed him ice chips with blue food coloring. In that way we could tell if the stuff he was coughing up from his trach was aspirated ice chips.

It was. Every time. Blue phlegm.

The other thing I remember is that his wife came to see him every single day and would stay for a long time. Maybe she had no other obligations, maybe she did but made him a priority. I don’t know – all I know is that she was there.

This brings up a few things that I’ve been thinking about lately. I realized that for the majority of my patients and their family members, their loved one being critically ill is the first time they’ve ever seen anyone so sick before. Through hope and a misguided sense of medical science’s abilities to cure, they have unbridled optimism. They don’t see the same cases day in and day out. Just as when I was first exposed to someone so ill, they don’t realize that there’s really a chance that the patient won’t recover.

This realization has gone a long way towards clarifying the thought process that goes into making someone who is obviously (to me) terminal a “full code.” With the patient that I described above – I think it would have really shocked me if someone had suggested stopping treatment and letting him die.

The other thing that has been on my mind recently is the availability of those making decisions for the patient. We recently had a patient that was in ICU for over 3 months. It was clear to many of us nurses that she would never, ever leave the hospital (and turns out, didn’t leave the ICU for more than a day or so on transfer before she’d be back). The family was adamant that everything be done for her and she lay in that bed and wasted away day after day. Her labs became increasingly abnormal. She developed bedsores despite frequent turning and skin care. She was trached and was on the ventilator. She was fed through tubes. She closed herself off from almost everyone, even nurses that she used to smile at before. She would barely look at her family… but there’s the thing. The family. That family was there every single day to watch this unfold. Did that make it right? I don’t think so, personally. But it made it a little better in my mind. At least they were taking responsibility for their decisions. They were at the bedside every day, watching the patient deteriorate as the months went by. That really meant something to me.

Yet a few rooms down, there is another patient in a similar situation. This patient is also trached and is fed through tubes. It’s impossible to get him off the ventilator. The times that he has communicated with us through writing, he has told us that he’s ready to die. Ready for this to be over. But his family is making the decisions. They’ve decided that everything is to be done for this patient. If his heart stops, we’re going to pump his chest and try to get it restarted. Yes, the family knows his wishes – they’ve seen what he’s written. They won’t accept it.

The difference? The family very rarely comes to see this patient. Maybe once or twice a week for a few minutes. They’ve put this patient in hell and now they won’t watch it. They won’t watch what they’re doing to him. They aren’t present for the times he coughs and needs suctioning. They aren’t there to step out of the room so that we can clean up his incontinent bowel movements.

They just aren’t there. I think it’s one of the saddest things I have ever seen.

Working in an ICU, there are of course instances when we decide to stop aggressive measures for our patients. One of the newer nurses (to ICU) had a patient whose family decided to stop ventilation and pressors. When the patient was extubated and pressors discontinued, we began waiting for the inevitable.

The patient had a permanent pacemaker, however. While he was being supported, his heart rate was sufficient enough to not need the pacer… but when we took it away, his heart rate started to slow down, as was expected. This is when the pacer started to kick in. The nurse asked how she would know when he died (from outside the room, just looking at the monitor) if the pacemaker just kept going. We told her that sometimes the heart just stops responding to the pacer and all she would see is pacer spikes on the monitor with no resulting heart rhythm.

One of the more experienced nurses mentioned that it was possible years ago to just put a magnet over the pacemaker (which is implanted in the patient’s chest, but is usually visible as a lump under the skin) to shut it off. She then added, “But with these newfangled pacemakers, you probably have to turn it off using a computer.”

Can you imagine emailing your pacemaker to tell it what to do? That would be a bad address for the spammers to get their hands on.

Several years ago, I came to work and took report on a patient that was very close to dying. For some reason, the curtain to the room was mostly closed, and I couldn’t see the patient well. When I looked at the monitor, I saw that he had a pacemaker and had pacer spikes, as well as “capture.” Capture is when the heart responds to the pacemaker and beats accordingly. I finished getting report – the offgoing nurse said that she last checked on the patient about an hour before and he was unconscious but breathing. I decided to check on my other patient first and got caught up in doing tasks, but every time I came out to the desk, I would glance at the dying patient’s rhythm and it was always the same – pacer spike, capture.

By the time I got into his room to see him, I found that he had been dead for quite some time. He had that lifeless look about him, and the absence of respiration also tipped me off. There was of course no pulse, but up there on the monitor was a consistent and unwavering spike-capture rhythm. I learned a very important lesson that day – you can be in PEA with a pacemaker too.

Every procedure done in a hospital has risks. You even have risks going into a hospital. It’s a pretty germy place, seeing as how people usually go there when they are ill. And even the most seemingly innocuous treatments or procedures can lead to more problems. IV sites can become infected and phlebitis can occur. You may have allergic reactions to the medications that are routinely administered for your condition.

Some people just have bad luck, I guess. We recently had a patient, a very elderly woman, who fell and needed surgery. While doing a workup for surgery, all kinds of labs and tests are done to make sure that the patient will survive anesthesia. Of course, this is usually the point at which some elderly people are diagnosed with a plethora of conditions. She did have some issues with her bloodwork and while correcting those issues, she had a bad reaction to the treatment. This reaction was the reason she came to ICU.

We worked to correct her imbalances but it became clear that she would not be able to go to surgery that day. She was in a lot of pain, which we tried to manage as best we could. The pain medicine made her itch. The other pain medicine we tried made her confused.

When she finally had surgery, it was determined that she would need invasive lines to monitor pressures in her heart and lungs. I shall qualify this by saying that she weighed about 100 lbs … and putting invasive lines into someone so thin runs the risk of puncturing a lung.

Where do you think this is going?

She did fine after surgery, was extubated in the recovery room and returned to our unit (with invasive monitoring line still in place) on nasal cannula. A few hours later, however, she developed respiratory distress. Another chest x-ray was done and it showed a very large pneumothorax. Her lung had been punctured. Yet another doctor was consulted to put a chest tube in.

She certainly wasn’t thrilled by the prospect of having a doctor come to insert a large plastic tube into her pleural space, but if it would help her breathe more easily, then… well… how could she say no?

The chest tube insertion went smoothly and we all expected things in that room to calm down. And they did. I kicked the family out and the patient napped off and on and seemed more comfortable overall, although still not as comfortable as I’d expected. The post chest x-ray showed that the chest tube had gone more towards her back than up towards her collarbone, but the doctor was hoping it would work well enough.

A few hours after all the drama, my patient put her light on. When I went to answer it, she said that she felt as though her “boob was bigger.” Her chest wall on the tube side definitely looked a bit larger and had the rice crispie characteristics of subcutaneous emphysema, which can be a complication of chest tube insertion.

I notified the doctor and was told that she was elbow-deep in someone else’s chest in surgery. As my patient was not in any distress, we agreed to keep an eye on it for the time being.

Another hour went by and I went to check on my patient, who appeared to be napping calmly. She awakened when I smacked her bedside table with my leg (ow) and I casually looked at her chest again. The swelling had definitely increased and it was very visible on her small frame. She appeared as though she’d been bench pressing, but on that side only. I called the doctor again, who still couldn’t come. I called her partner, but he was far away at another hospital. My patient still wasn’t in much distress, so I just decided to get another chest tube setup ready to go for when the doctor could get there.

The next time I went to check on my patient, I could see from the door that her chest was still bigger yet. We discussed how she was feeling and she looked down at her chest and said…

“Well, you tell those doctors that they have another thing coming if they think that I’m going to pay for this implant!”

Even though she’d endured complication after complication (and complications from the treatments for the previous complications), she still had a sense of humor. I love patients like that!

I called the doc again and informed her that our patient had gone from an A cup to a double D and that she really needed to come and fix her. She came over as soon as she could, still in surgical cap, shoe covers and face mask. We got another chest tube in the patient and she was finally 100% comfortable with her breathing (well, as well as you can be with two large plastic tubes sticking out of your chest.)

I was off for a few days after that, and when I came back to work I noticed she had been transferred.

Hopefully she got out alive.

Imagine this: a very thin elderly woman in a hospital bed. A list of her medical problems would be longer than your forearm in 12 point type. She’s been very ill for months. She can’t eat and is fed through a tube. At one point she couldn’t even breathe on her own and was on life support. Her kidneys are failing and she is on almost-daily dialysis, which she sometimes cannot tolerate without the use of vasopressors. Her circulation is bad. She has a massive bedsore on her tailbone and her foot is starting to turn colors. Bad colors.

Over the last few days, she has grown increasingly unresponsive. Sure, she’ll open her eyes when you say her name, and she’ll barely move her head in response to questions. But for the most part, this woman who would clearly call “Nurse!!! I know I want something, but I don’t know what it is!” last week is no longer even verbal now.

As I go about my day, preparing her medications and changing various dressings, I wonder what the point is. She’s clearly dying. She has tremors, so the pulse ox on her finger sometimes doesn’t read correctly; I have already gone in the room 20 times to adjust it. Usually it shows that her oxygen saturation goes from 98% to 60% in the space of 10 seconds, which is just not altogether possible… hold your breath for 10 seconds. I can guarantee you’d still be in the 90% range.

Except for this time. This time, I’m sitting in front of the monitors charting, and I hear the familiar dong-dong-dong and look up. My patient’s pulse ox is reading 80%. I figure that her tremors are acting up again for the billionth time (and resolve to put the damn thing on her ear next time I go into her room) and continue charting.

Dong-Dong-Dong.

Perhaps 30 seconds have gone by. The monitor now senses that her pulse ox has gone to 60%. (DING! DING!! DING!!!) We’ve been here before, several times. I sigh and look up from my charting just in time to see her heartrate go from 110 to 54.

Crap!!

I run into the room where I see that her pulse ox has a nice, even waveform. Definitely accurate. Although her heartrate has come back up to the 80′s while I was rushing into the room, her pulse ox is definitely in the 60′s, and although her chest is moving, there is no condensation on the inside of her oxygen mask. She isn’t breathing effectively.

I have some choices at this point. It would be entirely appropriate to find an ambu-bag and put the form-fitting mask over her mouth to force air into her lungs while I call for help. But for some reason, my instinct tells me to grab the Yankauer suction and stick it into the back of her throat.

Her eyes are open, but they are staring past me. I watch as the Yankauer fills with copious amounts of pale yellow/tan mucus. Part of me is relieved – this will surely fix her right up. But it just keeps coming and coming – where was all of this crap stored for heaven’s sake??

Then it stops. I’ve lost suction. I look at the suction head on the wall. It’s still set to high. I look up at her sats. They’re firmly in the 80% range. I look at her mask. There’s condensation on the inside. Good. She’s moving air.

I pull out the Yankauer. What was on the end of it may very well haunt me for the rest of my days. It was long and the matter at the end was the size of a large marble. It was black and somewhat solid, not like sputum or mucus. I wiped it off with a paper towel, regained suction and stuck it back in her throat. More mucus, more sputum. Sats up to 92%, definite air movement. Whew.

I didn’t figure sending the product of my suctioning session for culture would quite help us figure out exactly what it was. After showing the doctor, he suggested that we send it to pathology.

After the excitement died down, I wondered just what I did for my patient. Sure, I kept her from suffocating, but if that had happened in a nursing home, where she wasn’t on a monitor… I can’t really say I felt great about “saving” her. Does that sound a bit callous? I’m just not sure what I saved her for. More bedrest? An amputation of her foot? More infection? More dialysis?

Interestingly enough, she became a different person after our little incident. She began speaking again within the hour. She began calling out for the nurse again. Her children came to see her and marvelled at how she was so much more alert and responsive than in days past. She insisted she wasn’t in any pain.

I had a few days off after that. I came back to work to find that she had coded and was reintubated the day after I had taken care of her. She remains that way now.

I also found out that what I pulled out of the back of her throat was described by the pathologist as “meat fibers.”

Meat fibers. In a woman who hadn’t eaten anything in weeks. No wonder it was unrecognizable.