Chaya 9,356 Views
Joined Mar 5, '03.
He has '15' year(s) of experience and specializes in 'Rehab, Med Surg, Home Care'.
Posts: 1,132 (20% Liked)
As 2015 was nearing its end, so too was my final semester of nursing school. My mood was good. I already had a job lined up, and I felt fairly confident that I would do fine on my final exams. Some time in those final weeks, however, a surge of anxiety came upon me. The cause of anxiety:
The ever-present beings that hung in every patient room, scrawled with beautiful calligraphy of the (mostly female) staff nurses. And yet here I was, with handwriting that resembled a cross between a serial killer's manifesto and a ransom note.
This was my fear. This was my anxiety. But I'm not really here to talk about handwriting. I'm here to talk about something that I think is probably a much more prevalent fear, especially among nursing students: the death of a patient.
I think one of the reasons the thought of death wasn't really at the forefront of my mind is because, as a student, I never saw it. Sure, my classmates and I were sometimes assigned sick patients. But they were mostly fairly stable. Any death that did occur during my rotations did so quietly, and behind closed doors.
My first nursing job wasn't much different. I worked on an orthopedic floor for six months. While complications can and do occur, all of the hip and knee replacements weren't leading to the demise of my patients. The most action I ever saw is when one of my patients oxygen saturation dropped to 86%.
She also had COPD. And she made it through.
Like I said, I only worked this job for six months. And while I normally stay with my employers for much longer than this, at some point during my time there, I caught wind of a job opening at another hospital in the emergency department. And that's where I really wanted to be.
I remember my first patient death pretty well. I'll call him Mr. Gonzales, which was not his real name. He wasn't too old, maybe in his 50s or 60s. He came in to the emergency room in cardiac arrest, his heart being mechanically stomped by the Lucas machine that EMS had placed him on. I was new at the time, maybe in my second month, still in orientation. I had no idea what to do (thankfully, everyone else did), so I tasked. I hooked him up to the cardiac monitor, placed a blood pressure cuff on him, then pretty much just observed. We didn't code him for very long before he was pronounced by the physician. His wife and daughter were outside of the room, and were called in. They were Spanish speaking, but the stillness in the room by both the patient and the staff told them all they needed to know. They started crying. The doctor instructed my bilingual preceptor to inform them of what happened. As if by magic, my preceptor pulled a box of Kleenex out of thin air and handed it to the patient's wife. He expressed his condolences (I think). I stared at the floor and uttered a "Lo siento", and my preceptor motioned to the door.
Back to business. I had to do all of the code charting. Phone calls were made to the coroner's office, the local organ procurement agency, and the funeral home. More code charting. Put a call in to the chaplain. Charting. Check on the family. Try to tidy up the room, bring in chairs, bring more Kleenex. Charting.
The chaplain came down and spoke with the family for the while. Then she came to me with a pink bag that contained a condolence card, a pack of Skittles, and a candle that the other nurses instructed me to never light because if I did, someone in MY family would be on that stretcher. Who knew nurses, with all of their anatomy and physiology and pharmacology, were such a superstitious bunch?
I was honestly a little confused by the latter gesture. Why was the chaplain offering ME condolence? I didn't know this patient. I never heard him speak. At the time, I honestly probably didn't even remember his name. I felt terrible for the family, of course, but even those feelings were muted by all of the charting and phone calls that I had to make. The whole ordeal had a very much "part of the job" feeling to it.
If there's some sort of macabre spectrum out there of "good patient deaths" and "bad patient deaths", then working in the ER probably falls more toward the left. We typically don't get to know our patients very well, especially the ones who ultimately die. If a dying patient comes to us, they're either stabilized, or they die within a short period of time. It's probably a cliche, but most of the death-related sadness that ER nurses experience is more for the family than the patient himself. And that can be hard. And it can stick with you. Luckily, there's always someone or something to help distract you behind the curtain next door.
I work in a busy but small facility, and it's not a trauma center. That's not to say that we don't get traumatic death, too. A few months after my first patient death, a 16 year old patient was brought into the ER. He had been shot. Many times. EMS was en route to the nearest trauma center, but had to divert to us because his condition was rapidly deteriorating. All of the doctors and all of the nurses rushed into the room, hoping against hope that there was something that we could do to be useful. It didn't work. He was pronounced about 20 minutes later. And it was devastating. What seemed to be his entire family was in the waiting room, and upon hearing the news, they (understandably) lost it. There was screaming. There was crying. There was punching walls. And our hearts broke for the family. But there was more. It was quickly determined that this was a gang-related shooting. And the patients friends began showing up en masse. As a result, the hospital was locked down. Triage was now taking place not in the waiting room, but in a vacant patient room behind the locked doors of the department. There were police and security guards everywhere. Our focus quickly shifted from the loss of the patient and his family members to the safety of all of the other patients.
Mr. Gonzales's family was beginning to file out. I was starting to think (hope) that his wife had cried as much as she could, but leaving him at the end of the night proved me wrong. After she left, my preceptor began instructing me in the ways of post-mortem care. He had been cleared by the coroner, so we were able to extubate him, wrestle the IO from his leg, and remove his IVs. I still hadn't really had too much of an emotional response to the ordeal. We got to the point where we were placing him into a body bag. I began zipping it, and stopped when I got just below his chin. And that was my moment. That's when the finality of it all finally struck me, after hours of calling and charting and cleaning. I began to feel that warm, stinging feeling behind my eyes. My preceptor was still present, though he was in the far corner of the room doing some other task. I wanted to make a joke, anything that would distract me from the emotions I was finally feeling. Instead, I looked down at the floor, uttered one last "Lo siento", and zipped the rest of the bag.
That was now YOUR patient, you acted correctly.
Your co-worker does not administer /or seek pain control for sickle cell patients. YOU must write Nurse Ratchet up.. and advocate for future patients.
I need to hang this mannitol, like, right now. Now he ordered 3% saline, isn't that for brain swelling? Oh my god, I hope this patient doesn't herniate. He just added an epi drip... we already have 4 pressers on this patient. Now he wants us to take her to CT. Do I have to go alone? Will the vent even fit in there? What do I do about all these drips...there are twelve pumps running... Where's her family right now? What if I can't handle this?
I stand at the bedside, watching the blood pressure cycle again. The last one was 32/10, that can't be right, can it? The doctor is in the room shouting orders at me and my preceptor. We're going to lose this patient. The med student has the patient's legs at almost a ninety-degree angle, trying in desperation to get blood flow to her core and brain. "You need to squeeze that bag, now!" I shove the blue key into the pump with normal saline running and rip the tubing out of the guide. I hold the bag over my head and squeeze as hard as I can with both hands. "Call a rapid response!" The doctor yells. "We are the rapid response, what do you want me to do?" My preceptor calmly replies. I can see the worry in her eyes. We're in the CCU; we are the rapid response team. Respiratory is here, she can't do anything else to help. "Come on you guys, what H's and T's are we missing?!" Well, she's obviously hypotensive, I think to myself. Other nurses flood in, doing things I don't even know they're doing. One is recording everything on a piece of paper. I've never seen her before, she must work out on ACU. My bag is running out, I yell that I need another bag of NS and someone says they'll grab more. Someone takes over for me because there are orders literally flooding my screen now. I run to the med room and grab two pressure bags.
These things suck, I think to myself. They're plasticky and poor quality. I'm back in the room and look at orders. Mannitol, norepinephrine, mag sulfate, bolus, bolus, head CT STAT, the list goes on. Before I can even leave the room, someone hands me a primed bag of 3% saline. I check it against the order and hang it, moving as fast as I can. The patient has a triple lumen central line, no available ports. What can I put this line on? It's saline, I can probably put it with the pressers, I think to myself. I don't have time to check the IV compatibility, this patient is dead or dying. I hang the 3% and Y-site it into the maintenance NS after guiding into the IV pump and programming it. Then someone hands me a primed bag of mannitol. Then the mag sulfate.
The patient had a bowel movement right at shift change, we haven't even cleaned her up yet. The doctor says "Alright, she's stable enough, we need to get her to CT." My preceptor chimes in "We're about to get her cleaned up because she's had a BM... can we do that before we take her?" The doctor looks annoyed. "I really think she needs to go now, you guys, come on, time is brain!" He has a good point, I think to myself. Respiratory comes because she's on a vent; we can't take the vent with us so she's forced to bag this patient all the way to CT and back.
Outwardly, I look mostly calm and confident. Inside, I'm terrified. What if I can't handle this? Maybe I shouldn't have gotten into nursing. There are no new orders right now, just a few antibiotics to hang. We get the patient cleaned up and her family comes in. I'm hopeful. Maybe she'll pull through. Or maybe that bowel movement at the beginning of the shift was when it all ended for her.
The shift goes on. There's so much to do constantly, I take a brief twenty-minute break to shovel some food into my mouth and rehydrate. Then I'm back in the unit, checking on my patient. Her family is never far away, they think she's going to be okay. "Can she hear us?" They ask, their eyes pleading for me to say yes. "Yes, and you should hold her hand and talk to her... tell her you love her and to fight." I'm lying, I think to myself. This patient is gone, she can't hear anything right now. It hasn't been confirmed yet, but I really think she had passed right when the shift changed. Respiratory therapy is back, putting an EEG on the patient. Looking for brain activity, I think to myself. The family asks what the leads are for. I've explained what the numbers on the monitor mean, what each and every line and tube connecting to the patient means. Respiratory quietly says the leads will check for brain activity. The doctor had explained that things don't look very good right now. The family remains hopeful. I check the EEG monitor. Almost every waveform is flat. "How does it look?" The patient's sister asks eagerly. "Well, I'm not trained to read these things, so we'll have to wait for the doctor to let us know what he thinks." The sister's face falls. "Oh, ok.
Can I talk to her?" She gestures at her sister, lying motionless on the bed. She's not sedated, in fact, she not on any medications to keep her sleeping. "Yes, talk to her, hold her hand, you won't hurt anything, it's okay to touch her." The sister, fighting tears, walks to the bed and grabs her sister's hand. "Please, you have to fight, you have to come back to us..." I can't take this. I start tearing up. "You are not to cry in front of patients." The words of my clinical instructor in nursing school flood my mind. I excuse myself "be back in just a minute," and go sit at my computer at the nurse's station. Tears are flowing freely. I can't do this. Why did I pick this job? I can't handle this day anymore. The charge nurse asks if I want to go take a break. I have an enormous amount of charting to catch up on, I say, and wipe my eyes. "Do you want a hug?" She asks. I laugh bitterly and say no because I know it will make me cry harder. I don't want the family seeing this.
I can handle grief. I've seen people die before. But, nurses are supposed to save lives. Why can't I save hers? Is there something else I should have done? What else can we do? The doctor is at my desk with my preceptor. There's another doctor next to him. They're going to test the patient to see if she has any brainstem reflexes. She won't, I think to myself. We gather supplies and go into the room. The doctor explains what they will do and why they will do it. The check her eyes for the doll's eyes; they don't budge when her head is jerked side to side. Failed number one, I think to myself. The other doctor, an emergency room doctor, uses a saline flush to squirt water into the patient's eyes to check the corneal reflex. No movement. I thought they usually to the cold water in the ears, I think to myself, but what do I know? She has no gag reflex at all. The family anxiously looks at the doctor. "She is not responding to our tests... I believe she is brain dead. I'm so sorry..." The family stands there, grasping what the doctor is saying. They all begin to cry. I can't help it, I silently cry with them. The doctor wants to extubate the patient. The family is in agreement.
We prepare the family for it, what it will look like. The doctor suggests I draw up some fentanyl just in case, so I do and re-enter the room with my stethoscope around my neck. The doctor explains we are going to shut off all the medicines that are keeping her alive, and then pull the tube out of her throat. I shut off the cardiac monitor, knowing it will alarm asystole in mere minutes. We pull the curtain and shut the glass door to the room. The doctor nods at me and I begin shutting off all twelve pumps, one by one, quickly but not too quickly. Respiratory therapy is there, red-eyed and grasping the ETT. The vent is off. The doctor tells her to pull the tube out. She does, and we all watch to see if the patient will take any spontaneous breaths. She doesn't, just a small sigh as her lungs relax. My preceptor listens to the patient's heart with her stethoscope, shakes her head and I do the same. No heartbeat. The family erupts in wails, the doctor silently leaves the room. What am I supposed to do now? I cry with them, I don't care if we aren't supposed to. I hug the sister, the husband, not only for them but for myself as well. We give the family privacy to say goodbye.
I cry the entire way home. I relive the shift, over and over and over. I have to go back tomorrow. Today was my Monday. I don't know if I can handle this. I cry myself to sleep. In the morning, I get up, shower, and get ready for the day. This is what it means to be a nurse, I think to myself. If this is what it is, I don't want to do it. I can't do it. But I do it, I go back. Because that is what it means to be a nurse.
The AL facility I just left allowed a residents family member ( a completely inappropriate total care resident) to have a nanny cam in her mothers room.
It was sad really because the Cena's there were all fabulous and went above and beyond to care for this resident. All that camera did was create a chasm of mistrust and bad feelings between the very demanding family member and staff.
Thus, no one wanted to be in this residents room caring for her. The daughter would call staff repeatedly throughout the evening to tell them her mother was up, or wandering or needed to go to the bathroom-you get the idea.
The ANA has an Advacacy Panal specifically adressing the issue of violence towards nurses in the workplace. They also have been doing research on unit bullying prevention, and changing the acceptance culture.
They have an E-book on the website that is really good called Not Part of the Job: How to Take a Stand Against Violence in the Work Setting its $28 for ANA members and $33 for non-members. eBook - Not Part of the Job: How to Take a Stand Against Violence in the Work Setting
They also have a lot of good resources and articles. It's really important that we stop accepting abuse as a byproduct of working in healthcare, and we take a unified stance against it. The ANA is also lobbying to make assault against a healthcare worker a felony offence (just like a police officer or first responder). It doesn't cost that much to join if you aren't a member and your membership dues are applied toward countless causes like this.
It sounds like this patient needed to have some limits set and enforced well before this happened. Patients who cannot behave appropriately and do not want to participate in their care can be discharged home.
We do not allow smoking in the hospital or on property, and we do not allow patients to leave the unit to smoke. Patients who leave hospital grounds without an order (these are pretty much restricted to our oncology patients who are going to family events for a very short period of time) are considered to have eloped the facility. They are no longer patients and if they are a risk (including things like having an IV in place) we call PD for a check the welfare.
If the patient hit your tech he or she needs to file a police report. That is never acceptable behavior, battery is not and never should be considered okay. I have sent patients to jail before for battery on a health care worker and would do so again. In my state it is a felony and I think it should be everywhere. Patients are in a position of trust with staff and if they abuse that position they need the same punishment that anyone else in a position of trust gets.
Ringing the call bell 15 times in 10 minutes is not even normal drug-seeking (in the pejorative sense of the term). That level of short term memory loss is more consistent with dementia. Did anyone ask for a psych consult to help get a handle on mental health issues that might be affecting her behavior?
Without having a fuller clinical picture, it's hard to be helpful other than to say that the first step would be setting firm limits that are consistently enforced by all staff. If admin isn't backing you up, that's pretty tricky.
I'm surprised that such a demanding patient wasn't traded to different assignments for so long. If someone is known to be that draining, our charge nurses do their best to A)give the nurse the lightest possible assignment with the demanding patient and B) not assign the same nurse repeatedly- to avoid such a situation. As for their right, just no. I have told many patients things like- I am happy to provide the best care I can for you in the next eight hours, but I will not tolerate abusive language behavior towards myself or my staff. I will call security if it continues to be an issue. Most people calm down after that. Especially an alert and oriented person? Unacceptable. I also find it highly unusual that your patient can do out and smoke, I haven't seen that yet in my hospital. I would question why management did not get involved earlier with this patient's behavior. It was clearly disruptive to everyone and should have been addressed.
Don't let this one experience drag you down too much. Focus on the positive experiences you've had, and will continue to have, after this miserable one. Good luck!
At my former facility each patient was presented with a patient's bill of rights and responsibilities, which included that patients would be cooperative with care and follow facilities rules that included no weapons and no smoking. They were also informed that infractions may result in discharge. And they followed through with it.
Use of any tobacco products, except for gum, patches or prescribed inhalers were not permitted on the grounds, for patients, visitors or staff.
Patients have absolutely NO right to abuse us. Her behavior was so far from acceptable and should have been addressed as soon as it started. It is not ok to abuse the call bell or to scream and disrupt the entire unit.
I can't believe the hospital allows patients to go outside and smoke. Both facilities I've worked at have been smoke free and the answer was always no to smoking- the patients were offered a nicotine patch. Staff also does not have time to babysit patients on smoke breaks- there are sick patients that take priority.
The culture on my unit is to not put up with this. We call alert and oriented patients out on their behavior all the time. I've told a patient before I'm there to help, but I am NOT their servant and the way they are talking to me is not appropriate.
I'm sorry you had to put up with this. Your charge nurses, manager, and supervisors should have had your back and should have addressed this disruptive behavior if the patient did not listen to you.
Well Davey - sorry it didn't work out for you.
Yes, I'm changing jobs and specialties and while I won't publicly reveal my age I've been a nurse 25 years and this is a second career.
Go for it!
Ah, the questions that our children ask: "Where did I come from?" "How does Santa Claus fly around the world in ONE NIGHT?" or... "Do you believe in ghosts, mommy?"
Some questions are easier to answer than others.
I have never seen a ghost--that ethereal mist that makes the hair on the back of your neck stand on end. The kind that makes the room suddenly turn bone-chilling cold. But that doesn't make me doubt their existence. As a nurse, I have seen their influence: the ghosts of the past--those shadowy glimpses of those who once lived, who never leave us. The ghosts of the present, who haunt us daily. Those of the future, who we would like to change, but wonder if we can.
It was a beautiful summer day, when the sky was so blue that it seemed endless. This outside beauty seemed an unfair contrast to the dark, gloomy room, as I held the hand of my dying patient. "Martha, is that you?" he said as he looked at me. "No, I am not Martha, I am the nursing assistant," I replied. I knew that he had lost his wife a few years ago.
"Martha, please stay, "he cried. "I am here," I said. "I am not leaving." He died peacefully, with his wife's name on his lips. On this day, I was the ghost.
I had another patient, a new mother who seemed overly concerned about everything that her newborn was doing or not doing. "I think his lips are blue!" she would say. Or... "can you please check his temperature again? He seems too hot." Or... "he just isn't breathing right." It was kind of driving me crazy on a day that was already busy. Near the end of the shift, I finally had some time to go through the rest of her chart. And there it was: She had lost her first baby to SIDS, when he was only two months old. On this day, her first baby was the ghost.
When I was a nursing student, I had to do my obligatory four-day rotation in mental health. I had mixed emotions about this. On one hand, I was thinking, this could be a nightmare, and on the other hand--it might just be interesting. It was actually a little of both. I was given a lot of autonomy at the facility, given that I was a nursing student. The nurse in charge basically said: here is a list of "safe" patients--you can give them their meds this morning. Um, OK. As I made my way around the unit, I wasn't sure what I expected, but I encountered patients who seemed very ordinary to me. Until I went into the fifth room. I heard voices from behind the closed door. I thought it was a private room. When I knocked and entered, there was a man sitting on his bed having a conversation. He questioned....and he answered. "Who are you talking to?" I asked. "The Prophet Elijah," he answered. What am I supposed to say now? I dove right in. "Can you tell me your name?" "God," he answered. Oh. I double checked his wristband, and gave him his meds, while he continued his conversation. On this day...the ghosts were within his mind.
It was a cold, rainy day in December. I walked into my patient's room, not knowing what to expect. The report on paper didn't look so good. Teenage mother, history of depression, history of abuse. The scene was surprising. A lovely, young mother sat in her bed breastfeeding her baby. "Look, she has latched on this time without help!" she exclaimed with pride in her voice. "Good job!" I replied, sharing her enthusiasm. Then I noticed another woman in the corner of the room. She sat in the rocking chair with a sullen look on her face. She looked unkempt and smelled of cigarette smoke. Her hands were shaking. "I need to get some fresh air," she said and exited the room quickly. My patient looked embarrassed for her mother. The mother didn't return that day. We had an order not to let the stepfather into the unit due to his history of abusing our patient. I got to know my patient throughout the shift. She was tearful at times. "I am so scared that I will end up like her...she has made such bad decisions...bring that %^hole into our house." I realized that the ghost of her future self was haunting her. "You aren't your mother, and the decisions you make will be your own," I said.
So many times in my nursing career, I have felt more of a counselor than a nurse. But I have come to realize that nursing is all of that--you can't separate taking care of the physical body from that of the mind and spirit.
We have to take care of the patients and their ghosts--they are all around us.
I bet you never do it again!
I am shaking, peds codes/death's and that she had been in the ER less than 24 hours earlier, I can't imagine a worse case. Thank you for sharing, I hope sharing the story also helps you deal with it.
Your Medical Director is an idiot. I did the same thing, except (thankfully) with an elderly man who came in via ambulance, ACLS in progress. The code was called soon after arrival. Several family were there, they saw his body and left, I took him to our morgue. About two hours later an adult granddaughter came in and wanted to see him.
Luckily I was the House Administrative Nurse, on the the 11 - 7 shift, so I had no one to answer to. I explained to the granddaughter that the morgue was old, not very pleasant, he would be on a metal slab. She still wanted to see him. I went ahead, made him a presentable, and brought her back. She was fine.
I wonder if I broke some policy? I would have done it irregardless. That is the good part about working nights. No administrators around to mess things up!
Lol, you asked for it....
f you remove fibroids, will it create scar tissue that can prevent implantation? And if you have a somewhat small tumor, can it grow bigger over time?
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