Wednesday, December 31, 2008

My Code (final post)

I go outside of the room to look for the flowsheet. Mrs. Wilson arrived at 11:00 am and it is 5:00 pm now and I have not had time to write down a single vital sign. The charge nurse comes by and we turn to look at Mrs. Wilson’s monitor as her blood pressures go soft and her heart slows. “She is coding again,” I say. “Stop saying that!” he says, but her pressures keep falling and her heart slows to a stop. We call for help, I take up position by Mrs. Wilson’s IV access, chest compressions are started. Maria comes and looks at me, waiting for a task. I make a gesture of writing in the air and she takes up the code documentation again. The charge nurse calls for the second code cart; we have used up all of the meds in the first one (the unit has two for 16 patients).

The code gets up to full speed. One of the nurses asks how many times we are going to do this. “Someone needs to bring the family!” I call out. This time my words find purchase. Eyes turn to the fellow. The rest of the team does not know about our conversation. Will she take this as a challenge to her authority? There is a moment of tension in the room. “It’s alright, go get the family,” she says to one of the techs quietly but audibly. The tech leaves the room immediately. We resume the code. In a minute the daughter returns. Right away, she starts saying “No, no, stop this, stop this.” With a signal from the fellow we stop. There is no heartbeat. Mrs. Wilson is dead. The daughter weeps. One of the nurses turns off the IV pumps. The respiratory therapist turns off the ventilator. The room clears out. The daughter leaves to tell the other family members.

My work is not done. It is time to prepare the body for viewing. Another nurse and I fill three garbage cans with used sterile drapes, packaging, empty syringes etc. Two laundry bags are filled with bloody sheets. I suction the drool from Mrs. Wilson’s swollen, lifeless face and wipe blood from around her mouth. The breathing tube and other lines need to stay in place in case the family decides they want an autopsy, but I remove what I can. I turn off the hissing suction at the wall and toss the canisters, half full with blood and mucous, into the trash.

I want the body to look as natural as possible. A small IV on the inside of Mrs. Wilson’s elbow catches my eye and I decide to pull it. It is a mistake though; blood pours out from the puncture and does not stop. I put a piece of gauze on the site and fold her arm over it to contain the bleeding. We put a fresh sheet over the body, up to the chin, and I leave Mrs. Wilson’s other hand uncovered incase someone wants to hold it.

The daughter returns with two younger siblings, but the site is too disturbing for them. The daughter asks if the tube can be taken out of her mother’s mouth. I explain about the autopsy issue and she brushes it off. “We do not want that.” I find Dr. Lew speaking with some other doctors outside of the room and tell him. I expect the customary resistance to the proposal, but Dr. Lew readily agrees. Maybe he does not want an autopsy either. I am disconcerted. What if the family regrets this later on? I reason with myself that if they want to pursue some kind of legal action that there will be plenty of information to work with in any case. I decide not to disturb them with my concerns and I tell the respiratory therapist that the family wants the tube out and the doctors are okay with it.

I return to the room and tell the family that the respiratory therapist is on her way. I disconnect the breathing tube from the ventilator circuit in the hopes that it will look a little better that way. The family is already on their way out though. A frothy pink foam starts making its way out from Mrs. Wilson’s lungs and dropping onto the bed. I am glad that the family did not stay to see this.

As I start to work on taking down the network of IV tubing from the pumps, a young doctor comes into the room. He must be the neurosurgery resident. It is as if he is trying something out on me as he starts saying things like, “She was doing well when we brought her down here. How could I have missed the early warning signs?” I am not having any of this though. Without looking up I say, “She was critically acidotic from 6 o’clock this morning.” This silences him. By now I have decided not to bother separating the IV tubing and I am cutting though the tangles with a scissors. Some of the lines have not been clamped and I tie the ends off to stop the fluids from pouring onto the floor. This kind of cutting could never be done in life and watching it seems to drive things home for the resident. Mrs. Wilson, a reasonably healthy middle aged woman, walked in for an elective procedure yesterday and now her body lies before him dissected and dead. The resident mutters loudly “Shit!” and exits.

The tube is out. The room is clean now, save the overflowing trashcans off to one corner. I turn the lights down and go to the waiting room to invite the family to return. At first I am not sure if they will come back again or not. After a few minutes the daughter returns with her younger sister. They are in the room alone together for only a minute. As they leave the younger sister is crying, “It does not even look like her!” I try to imagine what Mrs. Wilson’s face must have looked like in life.

It is 6:30 pm now. Finally, I sit down to write my nurse’s note and chart vital signs. Another nurse asks if I need anything and I ask her to print out the record of Mrs. Wilson’s vital signs so I can copy them to the nursing flowsheet. The computer data is not saved. The nurse returns looking nervous that I may become angry and informs me that the computer data has already been deleted. The asystole (no heart beat) alarms go off every two minutes until the patient has been discharged from the system. Discharging the patient erases the data. People usually ask the patient’s nurse before doing it, but not everyone knows what to do. Anyways, it does not disturb me. Maybe I am braver or more foolish, but I just do not see this being a problem for me even if something legal happens with the case. The code documentation is there and I put in a few estimated vitals from memory. I write an explanation in my nurse’s note along with a summary of the day’s events.

My shift is over now. I was tired at the beginning of this day, and now a peaceful sort of exhaustion is taking hold of me. I ask the night charge nurse if it is okay if I leave the tagging and bagging for them. Everything else is done. It is okay.

I get a few pats on the back as I am leaving. I think that calling for the family during the third code was particularly appreciated by the other staff. “I know you make more money as a floater, but you should come and work with us,” says one of the techs, a black woman with whom I have had some friction in the past, “We need more men here.”

Thursday, December 25, 2008

My Code (continued from previous post)

Dr. Lew has cut through to Mrs. Wilson’s abdominal cavity now. A clump of fatty tissue, the size of a squashed loaf of bread, is removed and placed to the side exposing the intestines. Dr. Lew probes with the suction, looking for pockets of blood. He sucks out 2 liters, but they had been expecting more. Through a translucent membrane at the bottom of the abdominal cavity we can see a large pocket of blood that has collected in Mrs. Wilson’s thigh (where the catheter was inserted for the original procedure). The doctors decide not to go after it. We have not found the cause of Mrs. Wilson’s decline here. “How is her lung compliance now?” Dr. Lew asks the respiratory therapist. “It is much easier to bag her now,” she replies. At least we have taken some pressure off of her lungs.

As the young doctors gather round, Dr. Lew rummages hand over hand through Mrs. Wilson’s guts like a boy digging in a sandbox. He takes her large intestine in his hand and shows his students the areas that have been denied blood flow – “this area is normal… this area may recover… this area will not recover and will need to be removed, but we will come back and do that later.”

As they finish, Dr. Lew takes sterile towels moistened with saline, lays them across her intestines, and tucks them in around the edges of the incision (an opening about two feet long and one-and-a-half wide), “so she does not eviscerate while being turned.” A plastic vacuum dressing is then applied and attached to the wall suction unit with plastic tubing. A steady trickle of pinkish fluid begins making its way over Mrs. Wilson’s shoulder on its way to the canister on the wall.

The whole procedure is over in less than half an hour. My dreamlike feeling returns as I watch the OR nurses counting out their instruments, making sure nothing has been left behind. “5-6-7 of this kind of clamp I have never heard the name of before, 5-6-7 of that clamp,” etc. I conclude that OR nurses are entirely different creatures from unit nurses. These two middle aged ladies are cool, calm and collected. As they focus on their work, they seem to see only an operating room around them. The OR must have sent their best.

Mrs. Wilson’s blood pressure has remained high throughout the procedure. I have been slowly backing down on the pressors and her systolic pressures are now below two-hundred. I have not had time to check orders since the code, what to speak of documenting vital signs. Labs must have been ordered after the code. I draw the blood from Mrs. Wilson’s arterial line and hand the tubes off to another nurse who labels them and sends them to the lab through the tube system.

Mrs. Wilson maintains for the next half hour or so. The charge nurse asks me how she is doing now. “She will code again soon.” I reply. “Don’t say that!” he says, but I need him to know I will need him to stay around. The fellow hangs around also, catching up on other work on the computer just outside the room.

The first labs come back just as Mrs. Wilson’s blood pressure drops out and her heart slows to a stop again. Her blood PH is still below 7. I call for the fellow and the charge nurse, max out the pressors on the IV pumps and take my position at the head of the bed where the IV access is. I lay out saline flushes and use them to chase the code drugs in. Maria, he nurse who was pushing the meds last time asks me if I want her to do it again. I shake my head and ask her to fill out the code documentation. The charge nurse continues to assemble the syringes of code drugs and hands them to me when it is time. I call out, “Epi is in, Atropine is in, Bicarb is in.” as I push them. Maria writes it all down. I call out, “Her PH is 6.97,” again, but it falls flat again. Compressions go on, the bagging goes on, more liter bags of saline are hung on pressure bags and infused wide open. After another ten minutes we get her back again.

The room clears out again as Mrs. Wilson holds her blood pressures of over 200 again for now. Soon it is just me and the fellow in the room. “What do you think is going on?” she asks. “I think her acidosis is stopping her heart and that it is also causing massive tissue death which is feeding her acidosis in a viscous cycle,” I reply. She seems to agree. I had assumed the doctors were on top of this, but I begin to wonder if I was wrong. “So what do we do?” asks the fellow. “Well, I think the bicarb is what is bringing her back, but it is only going to be temporary. She is going to continue to code. I think you need to talk to the family.” She agrees. I suggest turning the bicarb drip up to buy time. She agrees to that also and I turn the rate up to one liter an hour.

Soon the fellow and the Mrs. Wilson’s daughter are in the room talking. I go to a computer to check orders and to give them space. From the hallway I hear the daughter, who appears to be in her late twenties, protest, “What is going on here!? First they told me her heart had only stopped for a minute and now you are telling me it was stopped for ten minutes! What is happening here?” The fellow must be telling her that there has probably already been a lot of brain damage and that it might not be the best thing to continue trying to save her.

The fellow leaves the daughter in the room. I go in to check the pumps and clean up what I can. Mrs. Wilson’s body is covered with a sheet to hide her incision. “Oh Mom,” says the daughter, her voice cracking a little, “I’m sorry I did not come around more.” She asks if pink fluid in the suction tubing is coming from the procedure that was just done. I tell her that it is. She stays for a few more minutes in silence before returning to the waiting room.

To be continued.

Friday, December 19, 2008

My Code (continued from previous post)

The nurse who was taking care of Mrs. Wilson in the Neuro ICU seems a little reluctant to leave, but she tells me what she needs to and goes. I keep busy getting the room organized. I am still getting acquainted with the tangles of IV tubing when Mrs. Wilson’s blood pressure drops out and her heart quickly slows to a standstill.

I call out for help and the room is soon flooded with staff. The code cart arrives and a nurse opens the drug drawer and begins screwing together the syringes of epi, atropine, bicarb, etc. I am with the IV pumps, on the opposite side of the bed from the IV ports that need to be used for pushing the code drugs, so another nurse starts pushing the drugs the doctors are calling for while I increase the doses on the drips that are already running. The epinephrine drip was already over the suggested maximum dose. Following the doctor’s instructions I max out the levophed as well. Mrs. Wilson is a big lady, so two of the techs perform chest compressions in tandem – one on each side of the bed pumping in unison. The respiratory therapist takes Mrs. Wilson off the vent and uses an ambu bag to ventilate her by hand. She says Mrs. Wilson’s lungs feel stiff. The nurse documenting the code keeps track of the timing of the doses of code drugs, calling out every two minutes when another round can be given. I call out to the room that Mrs. Wilson’s PH is below 7, but it does not seem to register. The pumps are now taken care of and I am feeling uncomfortable that I do not have an active role in the code any more. It is my patient. I should be pushing the drugs. It is like someone else is doing my job for me. The other nurses may feel I am not up to the task. Nothing to do now but endure it though. We keep pushing bicarb every two minutes. That should help if anything can.

We keep going for ten minutes or so. Suddenly Mrs. Wilson’s heart starts to beat 120 times a minute. Her blood pressure shoots up to the 230’s. The chest compressions have pumped the code drugs to her heart apparently and it has resumed its function. There is still no pulse-ox reading. Everyone stops and watches the monitor for a few minutes. When it becomes clear that the rhythm is stable for the time being, the room begins to clear out. One of the doctors tells me to start backing down on the levophed, but I do this conservatively. He seems to think she will be fine now, but with her low PH I am not so confident.

Soon word comes that the surgeons will be performing an operative procedure on Mrs. Wilson. They will do it here in the room since she is too unstable to transport to the OR. A team of nurses will be arriving from the OR shortly. I am to get the room and the patient ready.

It is just me and Hal in the room now. I pace up and down the room trying to clear space and do anything else I can think of while repeating out loud to Hal, “This is beyond my experience. I have never done anything like this before.” Eventually Hal replies that he has only seen it a couple of times himself. Apparently what mainly needs to be done is to pack absorbent pads under the patient’s body so that the bed does not become entirely soaked with blood. I help Hal get the pads tucked in from mid thigh to mid chest on both sides. They will be opening Mrs. Wilson’s belly.

Someone calls in that all the OR nurses need is an extra suction set. The charge nurse has been staying nearby and he goes of to get the supplies. While he is gone, the OR team arrives. Two OR nurses wheel in a cart full of instruments and begin to set up shop. They ask about the suction and we tell them it is coming. Dr Lew, the attending, will perform the surgery. Suddenly the room is full of doctors. The residents and interns will watch. A new fellow is also in the room. She ran the code, but her background is apparently not in emergency surgery. The attending jokingly invites her to do the surgery and she puts up her hands and takes a step backwards. Maybe by the end of the year she will be ready.

There is a dreamlike sensation for me as the world of the OR, which I have never really seen before, now invades my room and my territory. Standing at the side of the bed, I watch as Dr. Lew, who I have worked with before but never seen in surgery, takes a scalpel and makes a deep incision from just below Mrs. Wilson’s sternum down towards her navel. A faint smell of barbeque wafts through the room as Dr. Lew uses an electric cauterizing probe to stop any bleeding. We have the suction set up now, but when we hand the end of the tubing to the OR tech he barks at us, “This is not sterile tubing!” We stammer, ashamed “All…All we have up here is clean tubing…” One of the OR nurses has an idea and cuts the one section of sterile tubing they have brought with them in half. We use a connector to hook it to our tubing and the OR nurse gets the suction into Dr. Lew’s hand just a moment after he reaches for it for the first time.

I am pushed out of my bedside spot by a surgical resident who feels more entitled (fair enough), and I find myself standing in the second row, next to the fellow. As we observe Mrs. Wilson’s dissection, a thought occurs to her. “Have we given any anesthesia?” she asks me. I look into her eyes and shake my head slowly. For just a moment we both shudder, but it passes quickly. You would not, could not give such an unstable patient anything that might have a depressing effect on her physiology. Besides, Mrs. Wilson is not moving a muscle. She has been as still as a stone since she came from Neuro.

To be continued:

Sunday, December 14, 2008

My Code

There had been a question as to whether Hal (another floater like myself) or I would take the patient that was coming down from the Neuro ICU. I was assigned the empty room, but Hal, who was both more experienced and better known to the nurses on the SICU, had initially been given the patient and had taken report by phone already. I do not know what kind of calculations went on, but it was decided that I would take the patient after all.

Hal sat down with me at a computer and pulled up the patient’s chart. As we looked through her labs, Hal told me her story: Mrs. Wilson had come to the hospital for treatment of a brain aneurism. A catheter had been inserted at her groin and passed all the way up into her brain. When the aneurism (an out pouching of the blood vessel) had been reached it was “coiled” or filled with some kind of springy string (that is what it looks like in the pictures anyways). This had gone smoothly, but when the surgeons had tried to treat another aneurism they had found just past the first one, they “lost the coil” (in Mrs. Wilson’s body) and she had been spiraling down since then.

The exact cause for Mrs. Wilson’s rapid decline had not been determined, but she appeared to be going into multiple organ failure. She was coming to SICU to be started on continuous dialysis for treatment of a metabolic acidosis. Hal and I looked at her blood gasses (labs that show blood oxygenation, PH, etc). The metabolic pathways of the body require a slightly alkaline environment. Normal PH is 7.35-7.45. Anything below 7.20 is generally considered critical. At 7.0 the heart will stop beating.

It was 11:00 am. At 6:00am Mrs. Wilson’s PH had been 7.06. The latest blood gas had a PH of 6.98. Mrs. Wilson was about to code and die. “They should not be transporting her, they should code her there.” I say. Hal and I discussed what was going on. The neuro ICU is generally slow and they do not generally have a lot of codes. Perhaps they did not feel up to it. It is an ICU though and they should have been able to handle it. A nurse could be sent from another unit to help them with the continuous dialysis machine if they were not comfortable with it. Perhaps the doctors were trying to spread the blame. Mrs. Wilson would die under the care of General Surgery instead of under the Neurosurgery service.

The charge nurse, Mark, headed into the empty room to make sure everything was set up properly. “What is going on with that neuro patient?” “It is a dump, (on us by Neuro ICU), she is about to code.” Hal concurs “It is a dump,” he says. We will need backup.

Mrs. Wilson arrives with an entourage of two nurses, a neurosurgeon, a respiratory therapist pushing a ventilator, and a tech pulling two IV poles packed with at least 6 IV pumps - all running fast. Her blood pressure is low, her heart rate high, but the levels are alright for the time being. There is no pulse-ox (blood oxygenation) reading. We rush to get her settled in the room. I check Mrs. Wilson’s IV access. She has a central line in her neck and one on each side of her groin. There is a femoral arterial line also. I make sure I know which is which. There is no dialysis catheter. One will need to be inserted before she can get dialysis, if we ever get that far. I find the IV ports I will use for injecting the code drugs and another two ports that will be used for fluid boluses and blood products when they are ordered.

I turn to the pumps. Dobutamine, Levo, Epinephrine, (pressors for low blood pressure) all running near of above maximum allowable doses. At normal doses, a bag of these drugs can last a couple of days. These bags will need to be changed every couple of hours. I check to see that they have brought me spare bags. They have. Sodium bicarbonate is hanging. It is running at the standard rate. It is used for treating acidosis, but it will be like a garden hose on a forest fire at this point. I make sure there is a spare bag. Still no pulse-ox reading. No way to know if she is getting air or not. The mechanical ventilator is on high settings with 100% oxygen. That will have to do for now. Epinephrine causes vaso-constriction and can shut down peripheral circulation. The pulse-ox reads from peripheral circulation, so we may be out of luck. We can send blood gasses to the lab instead – it just takes half an hour or so to get the results back.

To be continued:

Sunday, December 7, 2008

If All You Have is a Hammer...

“No open heart patient, especially a fresh open heart, dies in this unit with a closed chest - that’s our motto.” This is from my orientation tour by an assistant nurse manager of another CTICU (Cardiac / Thoracic). She was pointing out which code carts were equipped with “chest trays.” I have not seen this so far, but a chest tray will be including some kind of scissors for cutting the sternum and an instrument for spreading the ribs. The idea is to have quick access of the heart in case a complication develops after surgery. The motto is about the ones that die. You can add something like, "whether there is any chance it will help or not," if you like. It is there silently already.

“When all you have is a hammer, everything looks like a nail.” That is my motto. I have noticed that all codes are not equal. In MICUs (Medicine), the codes are generally chemical codes – the doctors look at the patient’s labs and inject drugs to try to get the heart going and to correct any imbalances that may have caused the problem. I favor these over the other types because the doctors are more able to determine whether or not there is any point in continuing. MICUs tend to have the highest mortality rates in their hospitals because they get the endstage, inoperable cases. When death is expected, there is less need for dramatic gestures or heroic attempts.

In case my readers are not aware, I should mention that the statistics for meaningful survival of a real code are dismal – like why do we even bother dismal, maybe we are doing more harm than good dismal. By “meaningful survival” I mean a return to anything approaching normal consciousness and by “real code” I mean when there has been full cardiac or respiratory arrest. If memory serves, it is under 5% of those who are “saved” who ever leave the hospital (just like on TV).

In SICUs (Surgical) the surgeons seem to feel compelled to open the patient’s belly. This makes the least sense to me of all the interventions, but I gather they are looking to release pressure that may be constricting the lungs and for bleeds. I have seen this done a few times with no impact of the final outcome.

Trauma ICUs seem to favor chest tube insertion and their codes tend to go on and on. I saw one where the patient’s heart was stopped for fifteen minutes. We finally did get it going again, but what was left after that I would not care to speculate. After the code the charge nurse, Matt, gathered the rest of the nurses on the unit in another patient’s room to debrief. This is the only time I have seen this, although it really ought to be done after every code. I guess Matt was trying to seize the moment, but the choice of venue was unfortunate. The patient was totally out of it, but a relative was visiting. Matt had his back to the family member, who was standing just behind him. I have often wondered if the Matt realized the family member was there or not. The woman was so close to him, it is hard to believe Matt did not know. Maybe he thought it was another nurse.

Matt asked if anyone saw room for improvement. Not wanting to be too obvious with the visitor right there, I held out my arms and pantomimed ineffective chest compressions. Two male nurses and two female nurses had been doing the compressions. The patient had an A-line, so you could see the blood pressures they were generating. The men were generating systolic pressures in the 60s, which is pretty good for chest compressions, but the girls were only going through the motions, not even putting their weight into it, and they were not generating any pressure at all.

If you are wondering, I did not say anything during the code. I was just there for the day and the attitude was that trauma nurses were better than anyone else. Matt had been in there (he was one of the men who had given good compressions) and if he was not saying anything there was no place for me to. I was glad of the opportunity that came with the debriefing, but Matt just nodded and acknowledged, “The chest compressions,” without elaborating. Apparently he did not feel up to confronting the girls either. He moved on, listing his observations.

We had taken too long to put the back-board under the patient (this gives a solid surface to do compressions against instead of the bed mattress), and we had taken too long to bring the chest tube insertion tray. I watched the discomfort grow in the expression of the family member.

It had taken about ten minutes for the chest tube insertion tray to show up. The fellow who was going to do the insertion had called for it repeatedly with mounting frustration. Apparently it had not been in the usual place, but the task had also not been properly assigned and no one had taken ownership. Matt tried to put some gentle pressure on the nurses to do better next time, but the nurse who had brought the tray in the end felt accused and became defensive. Matt met her forceful renditions of various versions of “It wasn’t me!” with versions of “I am not trying to assign blame, we are just doing this so we can improve…,” but the nurse could not back down and the debriefing unraveled. The family member now seemed even more unsettled, but had no one to talk to. We disbursed and went our separate ways. I guess that is why we do not do the debriefings more often. Too much headache.