am finally used to hitting 4 on the elevator. I am used to all the new faces and they are friendly enough. What I am still working on is the patients. I can study all I want but there is no way to prepare yourself for the emotions you face when you care for a patient on a ventilator. That is just what I had to face on nights 4 and 5. And to further complicate matters I knew this patient. I knew this patient pre-ventilator. I knew this patient before it took 5 drips and a breathing machine to keep them alive. I knew them when they were talking, laughing, and eating. Now they are being fed through a tube that goes up their nose and down into their stomach. Now their family comes in shifts to see them and there is no laughter. This patient cannot even turn from side to side to keep from getting sores on their backside. This patient has to have a bed to do that for them. This patient has no idea that life is passing by right outside their eyelids. Time is going on without them. This is not the patient I know.
All of this hit me the minute I walked away from report and into that 10 x 10 room. That tiny space held 1 mechanical ventilator, 5 IV pumps, 1 feeding pump, 1 cardiac monitor, and one extra large Hill Rom total care bed. There was so much to do I didn’t really have time to think about the situation. Every tube must be labeled and placed perfectly to avoid causing tension when the bed turned. And they were tubes in every orifice: one in the mouth, the nose, the neck, the groin and even the rectum. That was just the first of my worries. I had 5 IV drips that I had to keep an eye on. Each bag had to be specially mixed by the pharmacy so if I let it run out I would be in big trouble. I had oral care and suctioning to perform every 4 hours and as needed. And then there is the family.
ICU stays are very stressful for the patient and many times even more stressful for the family. I want to do my best to make this time easy on everyone. If brushing my patient’s hair, cleaning their face and hands, and throwing on a clean sheet can bring them any solace I am going to do it if I can. So I brushed and I scrubbed and I sprayed on deodorant and misted some air freshener just in time for visiting hours to begin.
Every new family member that came in wanted an update. So I looked for the glimmers of hope in this dreadful situation and I repeated it over and over to every expectant family member. “No fever all day long.” “The heart rate is more stable than yesterday.” “Labs are holding steady.” I was trying to give them the information that they so desperately wanted but I was also trying to convince myself. This particular patient had a really rough time and had many preexisting conditions and it seemed like the situation was looking up for a while. The patient was extubated and seemed to be doing well and then everything changed and now they were back at square one.
So I spent night #4 with an intubated patient. I titrated drips until I went cross-eyed. I turned and I scrubbed and I tried to get the patient clean. I gave meds through an IV and through an NG. I did oral care and charted vitals and at the end of the night I still only had the gentle hum of the respirator whoosh as it breathed life into my seemingly lifeless patient. No big miracle. No flicker of hope. Just the mechanical whoosh of air in and out and in and out.
Nights 4 and 5 were back to back and I slept restlessly knowing I had to go back to care for the same patient again.
So we rushed through report and I flitted off to the 10X10 space to freshen up the patient before visiting hours. It had become my reprieve. The one thing I could do the entire night that gave me instant results. I was used to instant gratification. My patient has pain. I give the meds. All is well. Now my patient is sedated and intubated and I cannot always see the fruits of my labor. But I can tidy up my patient and see the eyes of the family light up when they come in. It is my salvation and it may seem like nothing but it is something I can do.
We were assigned to CODE team #1 for the night so if there is a cardiac arrest in the hospital tonight I AM YOUR GIRL! OH yeah now the fun starts. First night on the code team! Ok so truth is every night I am on the code team. I am the grunt on the floor and in order to learn I have been instructed to attend any and every cardiac arrest whether on the team or not. But still I am officially on the team tonight!! J
Visiting hours are over and it is time for assessment #2. While I am conducting this assessment I noticed my patient’s heart rate is up. Time for more titration. Heart medicine up. Of course if the heart medicine goes up then the blood pressure goes down. So blood pressure medicine goes up too. It is like this intricate little dance and there are no right answers. Just try it and see what happens. I am sitting in the room with my patient charting and pondering my next titration move when I hear the page overhead, “CODE BLUE 3 EAST SPOHN, CODE BLUE 3 EAST SPOHN!” OMG OMG OMG.
The time has come. I am on the code team and it is time to go NOW! My preceptor and I (well mostly her) sprint the 0.25 miles all the way across the skybridge to the other side of the hospital. She shows up first and then I huff and puff my way in, dripping with sweat, but ready to go. My preceptor starts recording what is going on and instructs me to watch. So as I am watching I notice my roommate, Brittani, standing squished in between the crash cart and the wall. We wave and then listen to what’s going on to see if there is anyway we can help.
Codes are crazy crazy times. There is someone doing CPR and someone intubating the patient. There is a doctor yelling out orders and about a million other people (mostly respiratory therapists) standing around waiting for the chance to save a life. “Give EPI now. Give ATROPINE. Anyone got the latest labs? What was happening when this occurred? What medicines is the patient on? What time did we give EPI? Is it time for atropine again?” Things can get pretty crazy. But then you hear “I feel a pulse! Someone get the blood pressure!” and everyone races to get the patient transferred to ICU in the few moments of stability. That is exactly what happened in this situation. And I just stood there and watched.. Talk about ANTI-CLIMATIC! I ran for this?!
My preceptor and I took our time going back. Even took the stairs once we got back to our side of the hospital. I am beginning to think she is trying to tell me something with all this exercising stuff. All was well when we got back to our floor so I decided to take lunch. During lunch I heard the nurse who was on code team with us talking about how the patient “coded” on the way to the ICU and she had to climb on the bed do CPR while going down the hallway. Ugh I officially missed all the action. FAIL.
Speaking of action, after lunch it is bath time. So we are going about our business bathing and what not when the ventilator starts singing. DEEDLE DEEEDLE DEET DEET! Oh no. Singing ventilators are NOT good. I look over and see a red flashing light on the machine. EEEEEEEK if singing is bad red flashing lights combined with singing is really really bad. I quickly give the tubing a once over and see nothing wrong but it is STILL singing and flashing. The patient’s oxygen level is dropping. OK there has to be something. Breathe and look for the problem Melissa! Then I see it the tube is disconnected. After a quick adjustment all is well and we can go about the business of bathing. Guess that’s what I get for moping about missing all the action.
The rest of the night goes by quickly and I am free at last. I am excited that these two nights are over. I can relax and sleep because I am tired! Honestly, at the end of the day, it wasn’t the hourly finger sticks and insulin titration that wore me out. It wasn’t bathing of the 300-pound patient. And it wasn’t the constant worry that I had titrated the medicine too low or to high and I would cause harm. See I could handle the manual labor and mental worry. It was all the emotions that wore me out. This is a new kind of nursing. The kind where saving the patient is not always the right answer. I had dealt with this before but usually the decisions are already made when they got to me on the floor. Now I am dealing with the intubated patient who has a family considering the placement of a permanent tracheostomy and feeding tube. These are big decisions and for once the decisions are not up to me. I am used to deciding whether or not to hold the heart medicine because the blood pressure is low. I am used to calling the doctor when I don’t know the answer. I am not used to standing back doing nothing. I am usually the decision maker and now I am forced to put my emotions on the back burner and carry out the family’s wishes. And it has worn me out.
let the fun fest begin… Soon I heard a familar story. This patient had cancer. Wasn’t feeling well. Came in through the ER and was admitted into ICU just in time to go into cardiac arrest. The doctors weren’t hopeful. They are waiting for all of the family to arrive. This was not my patient but I knew this nurse was going to need a lot of help. The phones were ringing off the hook and she was talking to a million doctors already… As soon as I assessed my patient and got everything up to date there I checked on her she was fumbling with the computer looking for a doctors number I offered to find the number and put out the page for her. When that doctor called back she and I were hanging blood. He ordered a ton of things then another doctor called and next thing I know there were three nurses running around just trying to keep this patient stable. Just at the moment I thought we were getting things under control the rest of the family arrived and we paged the chaplain because they decided to stop treatment. The chaplain arrived respiratory extubated the patient and then the moment of truth. All eyes were on the heart monitor. For 13 excruciating minutes I watched as the heart beat got slower and slower and started to get very irregular and then it just stopped beating all together. At that moment I decide now would be as good a time as any to do post mortem care. I offered to help and the nurse was happy to have the help. I was not ready for what was waiting in that room. I was not prepared for the cold skin or the still chest. As I took out the IV’s I didn’t know what to expect. I mean if the heart is not beating does the skin still bleed? The answer is yes and I couldn’t get it to stop. When holding pressure didn’t work I did the next thing all nurses do to stop bleeding. I held the arm in the air. Only this time the arm was rigid and slow to move. As we turned the patient over to change the sheets I could feel that the sheets underneath were still warm. I am thankful that this patient didn’t have to suffer too long and I’m glad I got to have this experience on a patient that was not mine. I was not personally attached and I didn’t even know an extensive history and it was still so hard.
