John was a nursing home patient who presented to the ICU time after time with respiratory insufficiency, sepsis, pneumonia, URI, UTI, you name it, he likely presented with it. His primary diagnosis was something like Closed Head Injury, or what is known as TBI, or Traumatic Brain Injury today. John was one of those patients that came in every once in awhile for a good healthy dose of antibiotics, a fresh Foley cath, and critical flush out his lungs and send him home. John was so predictable. After this visit was over, I would never take a patient for granted again.
When John showed up in the unit, he was non-communicative and usually in 4-way restraints as he would usually be doing a motion, we had coined as the crab. He would be on his back, moving each of his four extremities independently of each other, the way a crab would move, and this was in spite of having the 4-way soft restraints on. John was one of those patients that came in every once in awhile for a good healthy dose of antibiotics, a fresh Foley cath, and critical flush out his lungs and send him home. A couple of the nurses joked they could just about copy their nurses notes from the previous visits and use them for each time John came in, John was so predictable. After this visit was over, I would never take a patient for granted again.
Several years ago, I was working as Charge Nurse on 7p-7a in an ICU and we had a repeat customer from a Nursing Home, who came into the unit with some regularity because of his chronic respiratory status. Unfortunately, the nursing home where he resided was not known for their stellar care and John's lungs would be practically filled with mucus, before they would even bother calling rescue to transport him to our facility. We knew, when we learned it was John we were getting, to have portable x-ray and a vent on stand-by, and to be ready to incubate or even trach him, if need be.
John was usually in pretty rough shape for a man in his mid to late 50's, As far as we knew, there were no next of kin, and no one was listed on his facesheet as a contact, just the administrators of the Nursing Home. He was non-communicative and we just basically did our thing and restored him to as close as possible, to within normal limits as we possibly could, and transferred him out to the floor after a couple of days. This normally meant pulmonary toilet and sometimes we had to code him, sometimes not.
One morning, after a particularly vigorous night spent with John. We had coded him three different times and finally got him stabilized and got his blood gases where they were decent and he was bucking the vent, so we decided to try extubating him to see how he would do. I was standing beside his bed with another tube, just in case we had to re intubate him, and I was watching the monitor and watching him to see if how he was doing. It was our policy to have soft wrist restraints on all of our intubated patients so they couldn't/ wouldn't accidently pull their own ET tubes or anything else out. Still John maneuvered his hand over to where he could take my own and it startled me, but I tried to reassure him that everything was going to be alright and that he just needed to take some deep, but easy breaths.
Now, during all of John's previous trips to the unit, and there had been numerous, John had never spoken a word. He had in fact, barely done purposeful movement, but this morning John has taken my hand and he called me by my first name and said " Sam, You guys didn't do me any favors last night." I was dumbfounded. I couldn't believe my ears. I said, "Excuse me?" And he repeated himself, "I said, you guys didn't do me any favors last night." After I assured myself that he was stable and we wouldn't need to reintubate him, I excused myself for a minute, and went out and got another RN and asked her to come into the room, and asked John to repeat himself.
In the way into his room, I explained to her that she wasn't going to believe what had happened, and that John, who had been our patient for so long yada, yada, yada. She was more amazed than I was, as she had cared him before I ever came to work in that facility. At any rate, it turned out that John knew every nurses name and had just made a conscious decision not to speak. Now, he wanted to, and asked me if I would make him a no code, and he wanted to contact his brother whom he hadn't spoken with in over 25 years, but he still lived in this same city.
I asked John if it would be all right with him, if I shared this information with the Nursing Home where he lived and he grudgingly agreed it probably was necessary. John had one other request: he didn't want me to tell the nurses on the floor that he could or did talk, as he didn't want to into long drawn out conversations with anyone; he "preferred they just did their work, left him out of it and moved on to their next patient." I guess John got his wish, we never saw him again after that.
I visited with him once briefly, before he went back to the nursing home that time and I heard he came back a few weeks later in pretty rough, once again, but I never got a chance to go and visit with him. Funny, even for being non-communicative all that time, I had still grown quite fond him and he had taught some valuable lessons.
First, and probably foremost, I need to make more of an effort to determine if my patients are conscious and lucid. With John, I had simply gone along with previous examinations and only expected minimal neural output and that was what I got, instead of doing a full workup as I should have done. John had long since been diagnosed as TBI, Traumatic Brain Injury, or as it was called back them, Closed Head Injury, and his presentation was bizarre to say the least, but that was no excuse for our failure to properly assess his condition, not just once, but over a series of admissions. His grasping my hand and calling my name that morning clearly demonstrated he knew more about what was going on in that room than I did.Last edit by Joe V on Jul 29, '12
About FMF Corpsman
Joined: Jun '12; Posts: 196; Likes: 247
RETIRED RN; from US
Specialty: FMF CORPSMAN USN, TRUAMA, CCRNJul 29, '12This happened to me once on a smaller scale. Patient was declared to be non responsive and "actively dying" for the previous 3 days from the report I go coming onto the shift. He was living in a fairly nice ALF and one of the staff came into ask him what he wanted for dinner. I have a habit of talking to all of my noreponsive patients so I asked him if he would like something. He asked if it was beef brisket night and gave me the scare of a lifetime. Lucky for him it WAS beef brisket night.Jul 30, '12A long long time ago when I was an aide, I worked in a nursing home. It was my second day on the job and the charge nurse told me to feed Mr. Smith. She toldme he was old, crabby, and never spoke. I walked in his room with his tray, took the cover off the tray and said "oh...Let's see what dinner is tonight". He said "I ain't eating that sh@$ !" I almost dropped the tray. "They told me you never talk" I said to him. He replied, "They never say a word to me when they come in. Why should I talk to them?"Good point. That was more than 30 years ago and I've never forgotten him.Jul 30, '12WOW! That brought tears to my eyes! It sure does make you think though. I would take John speaking to you as a compliment of your caring and compassionate Nursing skills!Jul 31, '12I always talked to mine too, I just never got an answer from John. He would track me around the room with him eyes,so I knew he was "in there," but he would never answer a question or anything like that. He would even make those gutteral sounds some patients make sometimes, but that was it. SO my surprise. I was thrilled and honored, when he chose to speak to me. This isn't the first patient this that spoke with me, but that's a different story, maybe I'll tell that one too. But thanks for your comment.Jul 31, '12enlightening story and surely a lesson to be learn, thank you to the op for sharing this post with us...aloha~Aug 1, '12I had a patient who was "locked in". He was deemed to be a TBI "vegetable".When I started to take this case he was noncommunicative. He would show disdain by biting his lip or injuring his mouth some way. I figured that if he could show his anger then he DID have feelings. I started with the eye yes or no flutter. well he responded. Yes I want to go to bed etc. He had a history of loving christmas . I started playing Xmaw songs and when he heard them he smiled!!! I then started to take him to church early on Sun. am.s He was so communicative after the extra effort of getting him up and wheeling him to church.I was able to get him to cooperate and let me know what he wanted after he trusted me. I would not allow himto bite his mouth with out a stern lecture and after a while the only time he did a major bite was when he had a new nurse or if he was getting an infection when he felt painful.Aug 1, '12Quote from crazyoldnurseisn't it amazing what just a little extra effort on our part can accomplish? i used to pick up additional shifts at another hospital through an agency and was working in the neuro icu on a patient who was a young lady of around 28 years old, who had been there for quite some time, somewhere going on 3 months or so, as i recall, (this was probably 20+ years ago or so) she was in a coma and they were going to move her to the floor, but it turned out her family was quite wealthy and agreed to private pay, so she stayed in the unit. anyway, one day as i was getting report one day, the smart ass i was relieving, gave me a perfunctory report and said actually all we're doing is "weeding and watering her." the person who gave me report was another agency person, i had never seen before, and we all know how they can be, so i just wrote it off and since i’d been taking care of her for over a week now, i presumed i knew more about her than a report would likely give me anyway. i would just need to look at her latest labs etc. but, the more i thought about it the more irritated i became. and then i realized he was basically right. all we were doing was nothing care, making sure she was turned, labs, good skin care, etc, etc, when her husband came in at 7 for visiting hours, i proceeded to grill him... there were already all of these pictures of dogs, and people scattered around and taped to the sliding door. i asked him what the dogs name was, who the people in the pictures were, what her favorite foods were all of these personal questions about things i could talk to her about. i asked what kind of music she liked and listened to when she was in her car and at home. i had been talking to her, but about my life and things, i did, but that would bore the paint off the walls and send her even deeper into a coma. as soon as visiting hours were over, i started on operation wake up: i talked to her about her dog that was easy, because i’m an animal freak, if i hadn’t gotten into corpsman school; my second choice was dog handler. anyway, we talked about all of her friends & family and this went on all night. when i got ready to leave, i left my little radio on her music and ear buds in her ears. when i gave report, i told them about operation wake up. i wasn’t scheduled the next day, but i was off from the hospital, so i came in and talked to her all day long. each shift did a little of my "operation wake up," though, likely not as much as i did, as i usually found the radio on the bedside table. but still, a little better than 2 and 1/2 weeks later and this lady was awake! i don’t know if it was my constant nagging or not, but i like to think it might have helped. she got excellent care because her parents were wealthy no doubt about that. had she not been in the unit because of that, she never would have been there for that jackass to be rude about. i have this philosophy that we are all put on this earth to make an impact on one another, in one way or another. we may not know when it happens and it may not be a direct impact, i may impact you and you impact someone else, as a direct result of having been impacted by me, but in the end, it all works out for the best. just as it is supposed to.i had a patient who was "locked in". he was deemed to be a tbi "vegetable".when i started to take this case he was noncommunicative. he would show disdain by biting his lip or injuring his mouth some way. i figured that if he could show his anger then he did have feelings. i started with the eye yes or no flutter. well he responded. yes i want to go to bed etc. he had a history of loving christmas . i started playing xmaw songs and when he heard them he smiled!!! i then started to take him to church early on sun. am.s he was so communicative after the extra effort of getting him up and wheeling him to church.i was able to get him to cooperate and let me know what he wanted after he trusted me. i would not allow himto bite his mouth with out a stern lecture and after a while the only time he did a major bite was when he had a new nurse or if he was getting an infection when he felt painful.
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