Nursing Intuition, Part 1: The Visitor is . . . Dying!

[RobbiRN]

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 Girl

[debirn918]

Many 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.

[debirn918]

Another time while working labor and delivery, the patient told me 'I'm going to die, something's wrong'. I checked her vitals, assessed the fetal monitor and reassured her everything was okay. Then I had this feeling come over me, no-something is wrong. Called my Dr to come. Just as he arrived the pt. started bleeding a little, back to the OR we went, a significant placental abruption, but a healthy baby was delivered. Listen to not only my intuition, but those of my patient as well.

[maporcrn1]

As nurses, we have seen many things. We try to ease the patient's anxiety about non urgent matters. Cudos to you for recognizing her true sense of "impending doom"! I always hated if my patient said "I am going to die" or "I don't think I feel so good", right before passing out. I try to reassure the patient that I am listening to their complaint, assessing their status, that I am there to help them and will call for necessary support. Like you, I would rather be scolded by a doctor than risk the safety of the patient.

[jaycam, RN]

When I was still a student, I was doing med/surg clinicals at a trauma center. My patient had developed pneumonia and was sent for sent down for a thorocentisis. It had taken forever, and they were late for a neb treatment and pain meds. They were super irritable, and my nurse started all her meds, and we were going to leave it at that. I couldn't fight the nagging feeling though that something was out of character for the patient who was normally a sweet mama bear type. So I went back to the room just before planning to check on my other patients. She was coughing up white foam, had dropped the neb. Got them sitting up, grabbed an O2 sat on them (88) and dropped the O2 on them. Called for my nurse as I started listening and found the diminished lung sounds and crackles on the side where the procedure was done. We called a rapid response, I was told to handoff report to the RR team since I had been with her all day. The STAT nurse patted me on the back for catching it that quickly and ushered me out as they brought in the x-ray tech to verify findings.

[FurBabyMom, MSN, RN]

My first code as an RN was one of my patient's visitors. I will never forget that. I have never seen the water thing.

Another poster mentioned that hospice nurses have verified the water claim and request as having meaning. My personal practice has meant most of my comfort care patients are neurologically devastated and unable to ask. My personal experience was from my grandmother's passing, and she spent her last days kind in a coma-like state, seemingly unaware of her surroundings or those visiting her. She was peaceful though, so I have no complaints. I wasn't home during the final lucid days before that saga started, so perhaps I just missed it.

[Ruby Vee, BSN]

I, too have had the dubious please of coding a visitor. I remember the visitor who arrested while ambulating with his wife, the patient. Sad outcome. The visitor who choked in the hospital cafeteria . . . another sad outcome. The agency nurse who had an impressive, frightening seizure and ended up in the ER, and the nurse who got hit by a car right in front of the hospital. Then theres the intern whose shoulder I managed to dislocate accidentally. (Long story -- to make it shorter, I was holding his arm and looking away from him when he went down.) It's always weird when the visitor or staff member becomes the patient.

Years ago, a patient's daughter became quite agitated when her father passed away. It wasn't unexpected, and the family had been fully informed as to the likely dying process. Nevertheless, when he died, she began to shriek and to fling herself across the body. Her stepmother gently tried to remove her, and got decked for her trouble. The physician, quite disgusted with the daughter's behavior told me to "give her 10 mg. of Valium IM." I refused -- she wasn't a patient, we didn't know anything about her medical history -- but said I'd get her to the ER. The physician, already irritated, had a bit of a tantrum. My NM overheard, came out of her office and told me to just go ahead and give the Valium. I continued to refuse, and the manager told me "I'll give it. I want you to be in my office when I'm finished so we can discuss your continued employment."

I was sitting in the nurse manager's office when I heard the code called for the room of my dead patient. The nurse manager gave the injection and the daughter respiratory arrested within minutes. The visitor went to ER (and got intubated) and my manager apologized. The physician didn't.

[RobbiRN, RN]

I, too have had the dubious please of coding a visitor. I remember the visitor who arrested while ambulating with his wife, the patient. Sad outcome. The visitor who choked in the hospital cafeteria . . . another sad outcome. The agency nurse who had an impressive, frightening seizure and ended up in the ER, and the nurse who got hit by a car right in front of the hospital. Then theres the intern whose shoulder I managed to dislocate accidentally. (Long story -- to make it shorter, I was holding his arm and looking away from him when he went down.) It's always weird when the visitor or staff member becomes the patient.

Years ago, a patient's daughter became quite agitated when her father passed away. It wasn't unexpected, and the family had been fully informed as to the likely dying process. Nevertheless, when he died, she began to shriek and to fling herself across the body. Her stepmother gently tried to remove her, and got decked for her trouble. The physician, quite disgusted with the daughter's behavior told me to "give her 10 mg. of Valium IM." I refused -- she wasn't a patient, we didn't know anything about her medical history -- but said I'd get her to the ER. The physician, already irritated, had a bit of a tantrum. My NM overheard, came out of her office and told me to just go ahead and give the Valium. I continued to refuse, and the manager told me "I'll give it. I want you to be in my office when I'm finished so we can discuss your continued employment."

I was sitting in the nurse manager's office when I heard the code called for the room of my dead patient. The nurse manager gave the injection and the daughter respiratory arrested within minutes. The visitor went to ER (and got intubated) and my manager apologized. The physician didn't.

Ruby Vee, if you haven't written a book, you should. I'll be the first to get it.

[Ruby Vee, BSN]

Ruby Vee, if you haven't written a book, you should. I'll be the first to get it.

Thanks! I may try that when I run out of stuff to read.

[Lev, MSN, RN, NP]

I once had a young patient in the ER who was triaged as an ESI 3 for abdominal pain. "I think he's a bit drug seeking" I was told in report. The patient had gotten multiple doses of narcotics. I went in to assess the patient. He stated that he was in a lot of pain although he had just gotten a dose of morphine about 20 minutes before. I said I would talk to the PA to see if he could get an additional dose. I came back with more morphine which did not help his pain. The patient started getting agitated and snippy with me, but then he apologized for his behavior. The patient was becoming diaphoretic. He was also still in excruciating pain. Something did not sit right with me. I called the PA "We've given him a lot of pain medicine, but it's not touching him. He doesn't look good. I need you to take a look at him." The patient ended up being emergently rushed to the OR to removed a large thrombus which occluded his left femoral artery. Good thing the first nurse who had the patient had effectively assessed and documented the patient's pedal pulses. So when his foot went pulseless on us, it didn't look like we had missed this problem initially.

[Dizzyblue415]

I read this the other day. When I got to work my 84 y/o pt. Was asking for water. He was a DNR admitted for sepsis from multiple decubitus. All throughout the shift he asked for water. I related this article to my co workers. Almost there shift change in the parking lot I notified our NP that he probably would not make it to morning. He passed at 11 pm.

[Kooky Korky, BSN, RN]

I shall remember this lesson. The cry of the dying is for water. Memorable, hope I never need to use it, but so glad to have it in my orificenal. Thank you.

[Kooky Korky, BSN, RN]

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.

Read the poem "Gunga Din".