Working 7p-7a, what is on our minds at 6a? Our cozy, warm bed and counting sheep. This was what I was thinking of when a pt, we'll call him John... John Doe, came rolling into CCU.
He was a transfer from an outside hospital. Standard chest pain, had some nitro tabs, needed a cardiac cath. We see it all of the time. He was actually smiling and cracking a few jokes as we got him settled into his room (of course we're rushing - he's stable, we need to give report, and get home!). This is common too; pts tend to joke when they're a little scared or nervous. But it has been a long night for us nurses, the night is nearly over, and we're not feeling incredibly comforting at the time. I went home, and didn't think much else of it.
I'm back at 7p that night. I happen to peak in to see how John is doing. He had a cath. And in the process bought an IABP (for those non-CCUers ... it helps the heart rest and gives it more perfusion; usually when pts are in some sort of heart failure or cardiogenic shock, certain MIs) and some dobutamine. He's in cardiogenic shock. He's no longer smiling, joking, but rather he's sedated. He's not my patient, I move on.
Through the next few weeks, I just keep up on the progress of John. I watch him go through emergent intubation... twice. He weans off dobutamine... then is put back on. He's septic. Then he's not. He acquires a trach, C-diff, MRSA. Nurses begin to moan and whine "I have him again?" or "ugh, isolation!". He fails swallow study after swallow study. Mouth swabs and tube feeds are the only food he knows. One night I had him and when I ask "can I do something else for you before I step out?" He cracks a rare smile and writes "coke". I gave him diet coke mouth swabs - you would think the man was in 7th heaven.
Months later he moved out of CCU to a long term care floor. 2 days later, he was back in ICU with sepsis.
John had an ongoing battle with his family. They had hope that he'd get better - after all, he shows a good blood pressure and heart rhythm on the monitor, he's "breathing", so he'll get better... right? And he wanted to be let go. His body had tried to go several times to no avail. The family wanted escalation of care always. He did not. And doctors are too afraid of legal issued to listen to John.
This is the battle we so often see in critical care. What is "living"? This is different for everyone. But one thing John has taught me is to be the best patient advocate I can be. Nurses are often the best allies the patients have. We are the ones who bring the diet coke mouth swabs, fluff the pillows, see the best and the worst. And we need to remember that the trached, isolation, chronically ill pts are still people with wants and wishes.
As for John, he did finally get his wish - a nurse helped his family listen to him and his wishes rather than their own. :heartbeatLast edit by Joe V on Jun 16, '18
Aug 25, '08Sounds similar to a pt that I had this past summer. The difference was he had a CABG at 87. Was doing well afterward, then came the swallowing study with barium. The barium became like a brick in the bend of his descending colon. We tried everything to get it to move, but he eventually became septic, was intubated and sedated for what seemed like an eternity. Finally, the family consented to a colonoscopy. That along with a couple of other things, and the dr's were able to break it up. His bowels began to move. After what seemed like an eternity and with much antibiotics, he got over the sepsis. He was eventually trached and peg'd. He began to thrive. I was so excited, I'd had a small hand in the recovery of his near death experience. He was going to be moved to a trach weaning facility, and on his last day I went to stepdown to see him off. His family was in there jabbering away, and you could see his frustration. When he heard my voice, his head turned to me quickly, and with a great big smile he began to wave me to his bedside. I went and took his hand one last time and told him this would be just one small last thing he would have to endure before he could get the trach out and be back on his computer at home (where he wanted to be the whole time). He gave me that wink of approval/appreciation and I squeezed his hand as they were beginning the transfer. We said our goodbyes and I went on about my work. I thought of him often, wondering how he was progressing. Less than 2 weeks later, I came into work after 3 on 5 off, and one of the other nurses nonchalantly mentioned him dying "after all the bs we had to go through with him". I couldn't believe it, she had to be mistaking. I'd just seen him off, he was doing great. Five days earlier, he had expired at the facility to where he was transferred. I was crushed. It felt like losing a family member. No one else seemed to be bothered by it, so I was almost embarrassed to tell anyone just how I was feeling. Even though I was only an extern this summer, all of his care (except for medications) on my shift was my responsibility. It was my first experience with attachment and loss. Maybe that's why I was so bothered by it.