Think Before You Speak: The Last Words Your Patient May Hear

It is important to think before you speak because you never know who may be listening. In fact, it may be the last person you expected. The following story describes how one experience changed my nursing practice and how I provide care to all of my patients.

It was an ordinary Saturday and I was working as the day-shift charge nurse on the medical-surgical floor of a small community hospital. We were extremely busy due to it being flu and pneumonia season. As I worked actively on charting morning assessments, I heard the words "Code Blue" called over the intercom system.

It was protocol in our facility that all Registered Nurses (RNs) had to attend a code blue. During the week we had plenty of help when a code was called, but on the weekend we typically only had two RN's, a Respiratory Therapist, a clerk, and the physician.

When I arrived at the Emergency Room (ER), the ER nurse and the clerk had just gotten the patient transferred from the wheelchair to the stretcher. The ER nurse proceeded to give a report on what had happened. She said that the patient had been brought in by her husband complaining of difficulty "catching her breath" and some chest discomfort. The patient was awake and alert upon arrival to the ER, but was not able to speak. Before she could be transferred to the stretcher, however, she lost consciousness. She had no pulse and was not breathing.

We started CPR and contacted the on-call physician. Thankfully, it did not take long for him to arrive. Within a few minutes we had gotten a slow, weak pulse and had intubated her. She remained unconscious. A chest x-ray showed that both of her lungs had collapsed due to a large amount of fluid in her pleural cavity. The decision was made to insert chest tubes bilaterally.

Upon insertion of the right chest tube, a large amount of foul-smelling drainage shot out of the tube and across the trauma room. The same scenario happened when the left chest tube was inserted. Almost immediately, the patient started making an effort to breathe on her own. Her pulse rate had started to increase, but her blood pressure remained low.

She was receiving a large amount of intravenous (IV) fluids and had started to become edematous. I have always made a habit of talking to my patients even if they were unconscious. I explained to her that I was going to remove her rings because she was starting to swell, but since she was unconscious, she did not respond. I then proceeded to remove her rings, but found it to be very difficult due to the significant amount of edema that she already had in her hands. I remember telling the other RN that I was not sure if I could get them off and inquired about whether or not she thought we should cut them off. It was at this time that the patient took her right hand and grasped the rings on her left ring finger and wiggled them off. After getting them off, she reached over and handed them to me. Her eyes never opened the entire time, but she had tears streaming from them. We were all in disbelief.

I immediately started trying to calm her by explaining what was going on and informed her that we were doing everything we could to help her. She was still intubated and being bagged, but I made the decision to bring her family in one at a time, starting with her husband. When her husband entered the room, I handed the rings to him and explained what had happened. I informed him that even though she appeared unconscious, she was still able to hear him.

As he started to talk to her, the tears streamed down her face. It was truly one of the saddest things I have ever witnessed. Each one of her three children came in and were informed that she could still hear them. They spoke to her and told her that they loved her. Not long afterwards, she was airlifted to a larger hospital where she subsequently died shortly after arrival. The cause of her death was a ruptured esophagus.

I was so glad that I was able to give this family and the patient a few more minutes together. This incident also helped to solidify my beliefs in communicating with the patient even when it appears that they cannot hear the words that are being spoken to them. There are so many different experiences that I have had as a nurse, and each one has affected the kind of nurse that I have become. Some have made me stronger and some have made me realize how vulnerable I am. Although the outcome of the personal experience I described was a negative one, it made a positive impact on my nursing career and I will never forget her or the lesson she taught me. Every time I take care of a patient that I believe is unconscious, I think of her. Her death has affected the care of more people than she or her family will ever realize.