Monday, March 14, 2011

Nursing Instinct

It started with a feeling. You know, that gut feeling that nurses get when something is about to go wrong. They call it “nursing instinct”, but no matter the name, it’s never wrong.

My first assessment was nothing out of the ordinary. My patient was on the ventilator for recurrent sepsis, and looking to improve. She responded to my questions appropriately, nodding her head yes when I asked if she felt warm, which correlated to her above 100 degree F temperature. I offered her a cool, wet washcloth for her forehead and a fan, for which she smiled. I asked if she had pain, to which she shook her head no. I continued on, listening to her chest and abdomen, checking her pulses, looking over her IVs, and finished by asking her if she was okay, to which she nodded yes. I informed her I would be right outside her room and would be in periodically to check on her. She smiled, but something still did not feel right.

I sat in an alcove between her room and another patient’s, which allowed me to both see my patient, as well as her monitor. In report I had asked about the patient’s ongoing sinus tachycardia, to which the off-going nurse replied, “The doctors know about it. They’re not concerned, and just want us to keep an eye on it.” How many have heard the “keep an eye on it” warning? That set off an internal alarm, when I continued to watch her heart clipping along in the 130’s. Had it been that high all day? As I looked back in the telemetry monitor records, it seemed it had. I knew her heart could not stand much more after all she had been through.

But I was optimistic. Here she was, on the ventilator, no sedation, no pain, completely appropriate with talks of weaning in the morning. But then, her fever went up. It went up a whole degree in the course of an hour. I went back in to check on her, offered her some Tylenol, to which she eagerly nodded, and administered it via her OG tube. I thought, that the fever could be part of her tachycardia, that hopefully the Tylenol would help, which in turn would help decrease her heart rate. I wanted to believe that things were going okay for my patient, but that internal nudge would not stop telling me the contrary.

I went back to my alcove to start charting around 2100. I felt good about that at least. I had already assessed both of my patients and had given nighttime medications. Did I mention this was my 3rd shift on the floor as a new travel nurse, and my 1st shift on my own? The charting system was new to me, so I was glad I had a chunk of time to devote to navigating the charting system.

As I was in the midst of checking boxes and tabbing along, the alarm went off for my patient’s arterial line for a low reading. I looked at the tracing and wondered why it had dampened, when it was brand new that day. My patient still had an EKG tracing, but I went in to check on her to make sure she was okay.

I should also note that my patient was in droplet isolation. I gowned up, put on my gloves and mask and started in to see that my patient was not the responsive, bright eyed, smiling patient that I had come into that shift. I tried to rouse her several times, and then proceeded to check a pulse and did not find one. I called out to my (new) coworkers to call a Code Blue. She had pulseless electrical activity (PEA), which progressed to asystole. I started compressions almost immediately, her frail body surrendering to my hands pumping her chest. I could feel her ribs buckling beneath me. Must. Pump. Hard. It’s an indescribable sensation to feel someone’s ribs moving under your hands, as you try to do the work the heart cannot do itself. My coworkers ran to assist me, the Code team arrived, someone else took over compressions, someone else gave ACLS medications, and there I was watching (and also providing what I could remember about the patient’s condition and history).

They let her go with just enough effort and called the code at 2133, which was about 15 minutes after I discovered the change. Coming from an open-heart surgery background, I was astonished by the short duration of the code, but also felt at peace with it. I have watched a code go on for over an hour, thinking, when are we just going to give up? There are only so many medications you can give before the body rebels. I’m sure many of you have had this same thought, just know you are not alone.

What I have taken away from this experience:

That it can happen to anyone, anywhere.

That nurses are great team players when there is a code (despite non-code conduct).

That my nursing skills transmit to a variety of environments.

And that my gut is never wrong.

If you get the feeling that something is not quite right with your patient, but you can’t put your finger on it, you’re probably right.