Nursing Intuition, Part 1: The Visitor is . . . Dying!
All nurses have intuition. Sometimes it acts more like faith or an energy that takes us to the right answer well beyond reason. (This two-part series is connected to a giveaway in celebration of Nurse's Week, May 8-12. Share your own intuitive save story as a response to either article to be eligible for prizes to be announced next week.)
Nursing Intuition, Part 1: "The Visitor is . . . Dying!"
"How much damage to the car?" We're in the ER. EMS has just dropped off a young female driver following a motor vehicle crash.
"I'd say moderate. It was partly head-on, but more left front to left front. No airbags went off. Everybody was ambulatory at the scene. They all denied any injuries. Even this one originally refused transport, but she decided to get checked out because she's eight-months pregnant. Her cousin here was a front seat passenger, but she just came to be with her. She's not a patient." Tom is nonchalant. He's a good medic, generally concise and accurate in his assessment. "Any other questions?"
"No, thank you. We'll take it from here." I turn to assess the young girl strapped to the backboard. She confirms Tom's story. She's 21, in good health, denies any pain, and states she feels the baby moving normally. Her vital signs are good. "I'll get some help in here and we'll get you off this hard backboard."
"Can I get some water? I'm really thirsty." I glance across the protruding abdomen at the patient's nineteen-year-old cousin sitting in a visitor's chair on the far side of the stretcher. She smiles and shakes her head. "I don't know why I'm so thirsty."
This is where the big intuitive moment begins. All nurses have intuition; it's a hallmark of healers. Subconsciously, we listen beyond the words, pulling in nonverbal clues and relevant tidbits from previous experiences and a broad knowledge base. Sometimes, there may even be shades of clairvoyance, and our intuition acts more like faith or an energy that takes us to the right answer well beyond reason. Maybe it was the way she shook her head or her stated surprise at the sudden onset of her intense thirst. Maybe it was knowing that moderate front damage can cause serious injuries.
Inexplicably, I flash to a single line from a story I'd heard years ago: "The cry of the dying is for water." Three teenage boys were drinking when their car careened out of control, slamming into an old gumtree in the front yard of the person who told the story. He rushed out to find that all three of the boys had been thrown from the car. Two were not moving, but one was writhing slowing in the middle of the street. He ran to the boy and listened as he moaned one word over and over with his dying breath. "Water." The storyteller shared this experience to make point out that in the face of death there is a realignment of our values. He observed that the bottle of vodka was lying in the street beside the dying teenager, but the boy wasn't asking for that now. "The cry of the dying is for water. Just water."
I look at the young girl simply asking for a drink of water. She's clearly unconcerned about injury, but I can't ignore the "water" words flooding my consciousness now. "Are you sure you are okay? Does anything hurt?"
"I'm fine." She pats herself down and lifts her arms as turns her head side to side. "Nothing hurts. I'm just super thirsty. I don't need soda or anything--just water."
"Even though you feel like you're okay, do you mind if I check a few things really quick before I get you a drink?" I motion to an empty stretcher on the opposite side of the trauma bay. She agrees and lies on her back on the stretcher so I can check her abdomen. I pull the curtain, slide her shirt up, and see that her abdomen is smooth and flat. There's no seat-belt abrasion or discoloration. "Were you wearing a seat-belt?"
"Yes, but it was bothering my neck so I had it tucked under my armpit. I'm really okay."
I'm tempted to let this quest go, but "the cry of the dying is for water" words won't go away. I apply moderate pressure, palpating the lower quadrants. She denies any tenderness. When we get to the right upper quadrant, she winces. "Does that hurt?" I ask, adjusting the position and pushing a little deeper.
"Oh. Okay. That's a little sore there. Um, I guess it really does hurt right there." She suddenly looks worried for the first time since she casually walked into the department. Her radial pulse is thready, and the rate is about 120. Her BP is 96/48. Her palms are sweaty, and there's a hint of perspiration on her face. She looks a little pale now. Objective findings are piling on in support of my gut feeling.
The next few hours turn into a blur of lifesaving interventions. I physically drag the attending ER doc to the bedside where he supports my suspicion. We start two large bore IVs, draw labs, band her for a type and screen, and hang normal saline. We have her in CT in less than ten minutes, confirming a large intra-abdominal bleed from a lacerated liver, likely from her improperly placed seatbelt sliding under her ribcage on impact. Only one OR is available, and they ask me to scrub in because they don't have enough staff to handle the emergent surgery. For nearly forty-five minutes, I function as a human rapid infuser, standing at the head of the table to the right of the anesthesiologist, hanging unit after unit of blood and manually squeezing in several of them when her pressure drops precipitously. Additional OR staff finally replace me, and the surgery drags on for several hours.
I come to work early the next day to stop by ICU. She's on a vent, extremely edematous, looking like she is nearly twice the size of her slight build when she walked into the ER the day before. I'm told she received a total of 18 units of blood, but she is relatively stable now. Her puffy face looks peaceful. A tear rolls down my cheek as a surge of emotion reminds me just how close she came to dying. She eventually recovers and is discharged home.
We never know how many lives we save. Our intuitive moments are not always profound or memorable, but, for me, this one was unforgettable. Even though it happened years ago, any complaints of thirst in potentially hypovolemic trauma patients still grab may attention. This girl was minutes from death, and no one knew until a flash of intuition intervened. "The cry of the dying is for water."
EDITED BY ALLNURSES TO ADD
This two-part series includes a giveaway as one of the contests allnurses.com will be having in celebration of Nurses Week coming up next week. You are invited to share your own intuitive "save" story as a response here. The story with the top 10 "Likes" shared by the readers will receive a paperback copy of "Anonymous Complaint: A Nurse's Story." Those who share a story in response to either article will be included.
For Part 2 and details about a special Nurses Week Giveaway, see Nursing Intuition, Part 2: The Seizure GirlLast edit by Joe V on Jun 15, '18
About RobbiRN, RN Pro
I'm an ER RN, a writer, a traveler, and a lover of the beach.
Joined: Dec '16; Posts: 139; Likes: 720
ER RN; from FL , US
Specialty: 24 year(s) of experience in ERMay 1, '17Sitting at my desk as the evening ED Nurse Manager, I had a sudden feeling of disquiet. I felt I needed to go to the waiting room of the ED.I had made rounds just half hour ago but I went back.As my eyes swept through the waiting room, it stopped at an elderly black man who was sitting quietly surrounded by three young white adults that were chattering and trying to include this man in their conversations. He replied in monosyllables. He had a "sick"look and my intuition was screaming at me that something was wrong.
I casually walked up to him and asked him why he was there. He said he had a headache x 1 month and had tried Motrin, aspirin and other OTC meds. Nothing helped. I asked him who his companions were and he told me that they all worked with him caddying on the golf course .One of them told me that this man had a change in his behavior and that they were concerned and insisted that he be seen in an ED.. Digging further, I learned that the headaches started with a fall one month before and that he was on coumadin. I signaled the security guard for a wheelchair and wheeled him inside. I triaged him, threw a line and got the doc to put in for a CT head which showed a massive bleed. He was electively intubated, transferred to our main hospital Neuro ICU and recovered completely.The fall started the bleed a month ago, causing the headaches. He made the situation worse between his Motrin, Aspirin and Coumadin use.Thank God for ESP and intuition! That was a save from above!May 1, '17I've been a nurse 23 years - I've never heard about the dying calling for water before.
You truly do learn something new everyday, and never know when it will come in handy.May 1, '17Quote from 3ringnursingMaybe next week. . . Honestly, there have only been maybe three or four times the request was really significant, but when it was, it really was. I have found that hypovolemia does trigger thirst, just like low blood sugar triggers hunger. The resource is depleted and the body wants a replacement. We usually correct hypovolemia rapidly in a hospital setting, and they die from other system failures.I've been a nurse 23 years - I've never heard about the dying calling for water before.
You truly do learn something new everyday, and never know when it will come in handy.May 2, '17A few months ago, I come in and get report like any other shift. The final patient I get report on is one I had about a week ago so I remembered her. As the off-going RN gives me report, I'm looking at the patient and her vital signs. I've had many patients equally sick looking and with more extreme vitals but this was a total change from a week ago.
The off going nurse reassures me that she has been like this since yesterday and the docs had been informed and seen her. The rest of the report is all mildly reassuring.
Afterwards, I come back to the room to do a thorough head to toe assessment on the patient and the family had come in while I had been doing my start of shift routine of stocking my 100 pockets.
I talk to the sister, whom I remember from the last time I had cared for the patient. I don't even truly remember the conversation now or what sent my spidey-nursr senses tingling, but I paged the on call provider after I assessed the patient and just knew she needed a trip to ICU. Her resps were now in the 40s and becoming even more labored.
Long story short, cross cover doc came to assess at my urging and 100% agreed with me. ABG revealed that her case was emergent. Within an hour, the anesthesiologist tubed the patient and I started sedation. Charge nurse and bed management got me a bed and off we went to the ICU.
It all happened so fast and afterwards I realize I haven't even fully assessed my other patients and it's 11 something pm and no meds had been given. Thankfully the lovely nurses I work with had passed meds for me and updated me on my other patients. This definitely could have gone way different had I ignored that sense. Thank goodness I developed mine early!!May 2, '17Quote from RobbiRNMaybe next week. . . Honestly, there have only been maybe three or four times the request was really significant, but when it was, it really was. I have found that hypovolemia does trigger thirst, just like low blood sugar triggers hunger. The resource is depleted and the body wants a replacement. We usually correct hypovolemia rapidly in a hospital setting, and they die from other system failures.
When I worked ICU it was rare the patients I had could speak - nearly everyone was intubated. Even when we withdrew care we would still leave them intubated and turn O2 down to room air (it seemed more comfortable rather than the agonal, fish mouth gasping that would occur otherwise, which always distressed the family if they were present).
I floated to ER on occasion, but in a smaller hospital where nothing really exciting happened when I was there. No pearls of wisdom from that source.
A dear friend of mine has been a nurse for 37 years, and she worked hospice for quite a while - I asked her about the dying and water. What she said was, "Oh yeah … they always asked for it when the end was near. It was one of the 'unofficial' signs of imminent death". The new 5th vital sign? Apparently yes in hospice.
Thank you so much for teaching me something I had no clue about (there's plenty). It seems the longer I work as an RN, the more I realize I don't actually know. Nursing has a career long learning curve.Last edit by 3ringnursing on May 2, '17May 2, '17Powerful story! Good save! This is why we are trusted!
My dad asked for water just before he had a massive MI. He died as he was sipping the water at age 57. First MI.May 2, '17Quote from 3ringnursingAs noted above, hypovolemia is aggressively corrected in the ER, and dying patients are most often being bagged with a mask or intubated, so they usually aren't taking to us either. This confirmation by a hospice nurse who sees people die a natural death is impressive. They would know. Thank you for checking and sharing.A dear friend of mine has been a nurse for 37 years, and she worked hospice for quite a while - I asked her about the dying and water. What she said was, "Oh yeah … they always asked for it when the end was near. It was one of the 'unofficial' signs of imminent death". The new 5th vital sign? Apparently yes in hospice.May 3, '17It was a regular day in the ED. I had the back rooms, the "non-critical" patient's that are sick, but not needing to be in our (the nurses) line of sight the entire time. A woman came in complaining about n/v for four days. Through lab work and CT it was determined that she had gall stones, non-obstructed bile duct, but due to her n/v and dehydration she would be admitted to the hospital for 23 hour observation and IV fluids. No other medical hx, not even HTN! A nice, sweet lady.
I had just finished writing up her case, calling the floor to let them know she was coming, etc. I stopped by her room to ensure I had dispo vitals before taking her to the floor. She looked paler, a little more lethargic. Her VS were all still "in the normal range" but she was saying she was really nauseous again. I'd given her Zofran only 30 minutes before and it had worked well on her n/v the first time, so I was a little suspicious. I told her I would talk to the ER doctor.
Walking up to the ER doc, I asked the tech to do another EKG on her. I knew we had one one only four hours earlier, when she first arrived, but something just felt off. I put in the order and was going to talk to the ER doc when another, emergent pt. came in. He went to that patient's bedside and I decided to wait two minutes to talk to him, instead putting in the EKG order and entering my patient's newest vital signs.
Two minutes pass, the tech comes up to me with the completed EKG. It showed definite changes from the previous one four hours ago, but nothing "screamed" STEMI to me. Either way, I took it (and the previous EKG) and went to the doc. He looked at it and listened to my update. He immediately ordered another, right sided EKG and went to assess the patient.
Ten minutes later we called for Code 3 transport to another hospital with a STEMI center. She was having a right-sided infarct. I did all appropriate actions within that ten minutes--started a second line, administered aspirin, and gave another dose of Zofran. Total time from her complaint to transfer? Less then twenty minutes.
I shudder to think about what would have happened if I had just passed her complaint of feeling nauseous off on her gallstones. Transfers to a STEMI center from the floor can take *much* longer then transfers from the ER. I don't know what happened to that patient but I like to think that she's doing better now.May 3, '17I was at my afternoon job, running the after - school program at my children's school (my morning to afternoon job was as school nurse. My coworkers kidded me about never knowing who I was). A grandparent came to pick up a child as I was busy writing a receipt. "I will be right with you", I promised. The lady said, "I have a big surprise for you!" I looked up to see an attractive young lady in her late teens smiling down at me. I stood, proffered my hand, saying, "You have me at a disadvantage."
The grandparent said, "You really have no idea who she is?" I shook my head, feeling rather stupid. She replied, smiling from ear to ear, "You saved her life when she was almost a year old. We brought her to the ER one evening, and you were in triage. You took one look at her, picked her up, and took her straight back to a bed. I went back, too, and you made the doctor come see her right then. You went and got her nurse, too. You were so pregnant and so tired, but you did that for my baby. I can never thank you enough, but I have thanked God many times! She had bacterial meningitis." Then as my memory and my tear ducts overflowed, she called over her granddaughter, my patient's, daughter, and the three left gratefully together.May 3, '17Great Read!! Exactly what we are faced with on a daily basis. Love reading your writings!May 3, '17Many years ago, a young boy in my neighborhood was out riding his dirt bike and was in a seemingly mild accident. In a field, fell off and seemed to be in okay condition. He was just asking for water. Several hours later he was dead. I have always thought of this when someone is in the seemingly mild accident and asks for water. This is such a true reminder.
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