My feet started aching just thinking about it. Here at the nurse's station, the telemonitors were blocked by people trying to pick up their assignments. I decided to get the report first, then come back to see what my patients' heart rates and rhythms were.
The day shift nurse, Annie* was nowhere to be seen when I got to the end of the hall. But even with all the noise, I heard something else--wheezing. I followed the sound -- crackly rales topped by a short wheeze-- into the last room.
My jaw clamped trying to hold in my anger. The fellow was obviously in chief and it didn't appear that anything was being done about it. Yet I hadn't gotten report, so until I was able to take over, I had to withhold judgment. There was always some explanation, especially from a good nurse like Annie. I looked into the room at the patient more closely. The o2 mask was only partially on his face. I counted his breaths as I did so--34. No, higher. That did it. I went all the way in to assess him. He didn't see me yet. His arm came up and weakly swiped the mask off his face a couple of inches further.
The mask almost always made dyspneic patients claustrophobic. I gently replaced the mask and he waggled his head slightly from side to side. Listening to his lung fields with my stethoscope confirmed it--the poor man was in deep distress. Where the hell was Annie? I wondered angrily. He'd nearly worked the mask off again already in the few seconds I'd been there.
I tried to make eye contact with the patient. It would establish trust and help the patient calm down so he'd breathe more effectively.
"I see you're having trouble breathing." he didn't appear to have heard, but I continued anyway.
"I don't want you to waste your energy talking, just listen. I want you to try to breathe in through your nose, and out through your mouth--like this. You're breathing so fast, you're not getting any air, understand?" slight nod of the head.
Good, at least he heard me. He tried taking a breath in through his nose, but I could see right away that he was too confused and working too hard to continue. He resumed the shallow, fast breaths. " I'm going to pull you up in the bed so you'll breathe better." I slipped an o2 sat on his finger, turned up his o2 higher. 83%. I grabbed the top two corners of his cloth underpad and gently pulled him up higher in the bed. I didn't dare roll the head of the bed down, so I didn't get very good results. But it was better than nothing.
Annie bounded into the room. Her hair was clinging to her flushed, sweaty face. "oh thank god you're here--let me help you pull him up--I've been waiting for his doc to call me back for nearly an hour now." together we pulled him to a better position. Annie tried to give me a report. "you know he's going to slide right back down, don't you? --I'm beside myself on this crazy assignment," and to the patient, "please try to keep the mask on this time, it's helping you breathe, and I've already called your doctor." she shook her head, ruffled her hair, and flung her hands in the air as she gave me report. Report was partly report, partly vent about her impossibly busy day. "to top it all off, this poor fellow's in chf -he'd been downstairs for tests for hours, and they just brought him back like this--how could they do that-- and the last shift didn't give his lasix twice because his blood pressure's too low, and he just had 500 of Vanco and 250 of something else, so what did they expect, you know? And I just had another patient come back from surgery, and there's blood hanging on another one. I've been waiting for his doctor to call back-and on top of everything, I have no idea where the tech is and I've been changing and toileting people all day long." she was near tears, she was so upset.
Apparently, my face had screwed up into that oh god not again mix of horror, disgust, and pain that off-going nurses had come to know and love. She sniffed and continued, "'but don't worry, I'm not going to leave this mess for you. I'm staying till it's fixed; I wouldn't be able to live with myself if I didn't."
I was relieved that she volunteered to stay; together we could get everything sorted out and on the road to sanity much faster. I'd worked with her before and knew she was fast and competent. If Annie said it was a horrid assignment, it was.
"Ok. Let me take him, as long as you've given me some info, because he needs care right now, and you tend to the others. When you're ready, just let me know and I'll take the report on them then. Who's the doc that'll be calling back on my guy?"
"Liebowicz." cool. He was an awesome doc. For weeks when I started on this unit, I'd erroneously called him Dr. Goodman. I was terrible with names and both he and Dr. G were tall, dark, handsome types. Dr. Liebowicz took it with such good humor, he made my favorites list. I always learned new things from him too, which was always a plus.
Right on cue, Annie's cell phone rang. Relief. It'd be Liebowicz. I got her a new order sheet to write the orders on and stood ready. "right. Hold on and let me get the chart." she took the order sheet from me and walked across the hall to the post-op's room and pulled the chart.
Gah. It wasn't my guy's doc. Mr. Chf was still weakly trying to remove the o2 mask by moving his head, causing him to slide down in the bed until the mask slipped into uselessness.
I replaced it. "I know it feels like that mask is smothering you but it's not, it's getting oxygen to you and it's helping you breathe. Can you please try to keep it on?" his eyes were dull and he was slumping down in the bed again. I didn't think he even heard me, but I had to try to get his cooperation. I repositioned him as best I could and reassured him, saying, "we know how sick you are and we're doing everything we can to help you get better, ok?"
One thing was for certain, his heart couldn't take all this. I ran up to the nurse's desk and got myself a new cell phone and told the unit secretary that if the doc called for Annie, to transfer the call to me. While I was there, I checked out mr. Chf's heart rate--120-130, a-fib. Oh, terrific. Where was the doc, anyway? Where was the charge nurse? Where was everyone?
I'd been on the unit for less than 15 minutes. I trotted back down the hall. My cell phone rang. It was the doc for the chf'er. Finally! Annie was busy writing orders for the post-op patient. I decided to take the call, motioning to Annie that I had dr. Leibowicz on the line. Miraculously, that chart was on the rack. But I didn't know enough about the patient, so I stepped into the room and held the phone out so the doc could hear the patient breathe.
"hear that?" I asked. "rales throughout. Confused, tachypneic, wet cough, very floppy."
"Oh heavens," said the doc. "give him 80 of lasix." "I think his bp's been in the toilet all day and that's why he hasn't gotten any before."
Suddenly Annie appeared and I handed over the phone and ran off to get the lasix, scribbling the time of the verbal order on my kardex. When I came back, there was a laconic tech in the room trying to get a bp with a dinamap. I stopped her. "don't even bother," I said, grabbing the manual cuff from the wall, "he's in a-fib and it won't be right." I shooed her out of the room with, "we have an emergency here, could you please take care of the lights?" I was annoyed because this was the same tech that was watching tv in the break room when I clocked in. To be honest, I wasn't sure who I was angrier with - the tech who was obviously falling through her butt with exhaustion, or the scheduler who let her work five 12-hour shifts in a row. I took a deep breath and started counting to ten. This was not the time to confront the tech on the ignored call lights and the sloppy state of the other patients' rooms. This patient was in crisis and I had to concentrate all of my efforts on him and him alone.
His bp was 93 systolic. Good enough. I'd checked his history and he never was very high, to begin with. 80 mg of lasix was a lot for a bp like that but I'd just have to give it very, very slowly. I drew up the lasix. "wait!" Annie said. I stopped, holding the syringe in midair. "the doc says give him 40 slowly now and in an hour, give another 40 if his bp maintains over 88." even better.
I quickly wasted half of the dose and proceeded to give the 40 mgs. That gave me plenty of time to bond with the patient. Poor fella, he was really working hard to get air. He looked so ... Crumpled...So small, in that bed. He was barely responsive, not even trying to push off the o2 mask now. I'd push a little medication into his PICC line and pat his hand gently to comfort him. At some point, I realized that the don, charge nurse, and day shift nurse were all in the room quietly briefing each other on what was happening. They'd been helping at a code on another hall.
After a couple of hours, his breathing improved and his heart rate came down and his blood pressure, although on the low side, was stable. He slept. I checked in on him frequently, counting his respirations and pulse while I took his bp every half hour, then every hour until I was satisfied that he was out of danger. Around nine, his daughter slipped into the room. I found her standing silently at the foot of the bed, dabbing at her eyes with a wadded up tissue.
"It's so hard to believe that less than 10 days ago, he drove himself here because he was feeling a little short of breath," she said, shaking her head sadly. I murmured sympathetically, said all the right things, and got out of there quickly. As long as she was there, I might be able to catch up on my other patients. I didn't quite believe her when she said that he had his own apartment and took care of himself before this illness. Families always tended to exaggerate.
The rest of the shift went as expected--I was about an hour late getting out, but it was worth it because my little man was alive, had graduated back to a nasal cannula, respirations were in the '20s and I could no longer hear him breathing from the hallway. His heart rate came down to around 90 and his bp was hovering around 88-93. His foley was draining well, and when he opened his eyes, they seemed clearer. He was still pretty weak and I had to pull him back up in the bed every time I went in. I told him everything I was doing even though I knew he couldn't understand. It was such a habit with me to do that. "ok, I'm going to pull you up again, because it'll help you breathe better," or "I'm going to take your blood pressure again, make sure it's where it needs to be" or "this medicine will help you breathe better because it gets rid of the water." and "you don't have to talk, just concentrate on taking nice big breaths of air."
The night's activities were duly chronicled in the nursing progress notes and I made sure to mention to the oncoming nurse that the next time the family came in, someone needed to discuss his code status. "because he really should be a dnr, you know? Poor little guy, he hasn't really been responding all night."
Naturally, I had to stop in the next day and see how he was getting along. I waited till after dinner when it was calm, and snuck into his room and just stood there for a moment. "good," I said to the air, "I guess you must be better because I can't hear you breathing from the hallway."
I turned to walk away.
"thank you," said a voice. I almost jumped out of my skin. I spun around faster than a figure skater doing a triple lutz. But there was no one in the room except me-- and the patient.
I stared in amazement. The confused, nearly unresponsive patient had spoken?
"I almost died last night. You saved my life. I want to thank you for helping me."
I came toward the bed. He was sitting up and the head of the bed was up, not too weak to maintain position. His voice was clear and strong, not struggling to breathe. I could only stare in amazement.
You know, it's funny. I always told myself, all through the torture of nursing school and missed family gatherings, through the exhaustion of 12-hour shifts in which my livelihood and my person were routinely threatened, that if I could help just one person, that all my sacrifices would be worth it.
My golden moment touched down on the wings of that patient's thanks. It all had been worth it. Here was that "just one person."
I smiled and took his hand and shook it. "anytime, my friend, anytime."
*all names and some details have been changed to protect the privacy of those involved.
