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.”

1 comment:

dethmama said...

Great story, Leo!

And by the way, Happy New Year. May we all dodge life's "wandering coils".