A Patient to Remember

azhiker96, BSN, RN

Nursing always polls as the most trusted profession. That is not by accident. We work hard to earn and deserve the trust people put in us. Patients and families see that and appreciate our efforts. Often the most important things we do go unseen by patients and families. This is a story of how I lived up to that trust one day, with one special little boy.

(All names have been changed)

An OR room had called out. We were getting a 4 year old tonsillectomy patient. Deedee was next up so she prepared her bay; straightening cables, setting up the monitor, and logging into the chart. It is common for a second nurse to assist with admitting a patient. I stepped into that roll, asked if she needed anything, and stood by her side.

Deedee was in her first year as a PACU nurse. She was bright and caring. She had been out of orientation for a few months and doing very well on her own. I had worked in PACU for several years. I had a little more seasoning and a few more grey hairs on my head. We both knew that airways are fragile in kids, especially when they are sensitized by surgery. A little bit of blood or saliva can cause the glottis to clamp shut. When that happens, they have little reserve and crash quickly.

We waited for the patient to arrive. Soon we heard the cart rolling down the hall accompanied by the footfalls of the anesthesiologist and circulator. Brittany and I both slipped on gloves. Tonsillectomy kids tend to have a lot of secretions mixed with traces of blood. It's best to be prepared. We turned to watch the cart arrive.

The cart rounded the corner to enter the PACU. Automatically I looked at the patient and began assessing him from 20 feet away. I also glanced at the anesthesiologist. I had never seen him before. As I later found out, he was an adult anesthesiologist who had picked up the case. Happily, I never saw him there again. Back to my assessment.

The anesthesiologist, Dr. No, was holding a high chin lift. The chin lift was way too extreme for a child of that age. It alone could block the airway. From the time they rounded the corner until we were backing into the bay, the child made no attempts to breath. His chest and abdomen were still. No rise and fall, no fogging in the mask, not even any sign of retractions.

I began hooking up our monitors starting with the oximeter. I also told Deedee to assemble the bag valve mask. Dr. No said not to bother with the BVM but I told Deedee again to assemble it while I assisted with hooking up the patient. God bless her, she did as I asked. I love working with nurses I trust and that trust me.

The first reading on the oximeter was 60% and it was steadily dropping. Dr. No continued to hold chin lift as the child remained motionless and sats dropped below 50%. Then he asked if we had the BVM handy. Deedee handed it to me and I assisted Dr. No while she switched the O2 supply from mask to BVM and cranked it up to max flow. Dr. No held a high chin lift and clamped the mask to the child's face. Every time I squeezed the bag, oxygen blew through the seal between mask and face. The child's glottis had clamped shut in a spasm. That combined with the high chin lift to close off his airway and resist our efforts at ventilation. This was not looking good.

About this time another anesthesiologist, Dr. Angel walked by. He peered into our bay and asked if we'd like some help. Our response was instant and in unison. I said "Yes" while Dr. No said "No". Dr. Angel looked at the monitor over my head with a quizzical, confused look and then wandered off. A minute later I saw him quietly hovering near the bay with a few syringes in his hand. He had prepared Sux and a few other meds to be ready when we either asked for help or declared a code. At that time I knew he was my guardian angel and would be there instantly when we had to code the child.

It was now obvious that there was no oxygen reaching the child's lungs. The sats dropped to single digits and his pulse was slowing. I suggested perhaps I could hold the mask to the face while Dr. No operated the bag. He let me switch positions on the BVM. I used a jaw thrust instead of chin lift and secured the mask to face with my Cs and Es. The next pump of the BVM pushed oxygen through his closed glottis and produced a satisfying chest rise. We had finally broken the laryngospasm.

We bagged the child back up to 100% oxygenation and his pulse returned to a healthy level. It rose from a chilly night to about the same as a hot day in Phoenix. Dr. Angel silently left to attend his next patient. We paused bagging to see if he would ventilate without help. The child was able to breathe easily but only at a rate of about 2-3 per minute. I suggested that a touch of naloxone, maybe 20 or 40 mics, might be useful. Dr. No declined saying the child didn't need any Narcan.

All vital signs were now good except for his respirations. We had the BVM to assist with that if necessary. I turned to Deedee and said it looked like they could handle it from there. I said I was going to go to the Pyxis to dilute some narcan because it's just something I enjoy doing. I was furious at the doctor for twice denying the patient what I knew he needed. I wasn't trying to criticize his work. I was trying to save the child. I thought, "Please sir, check your ego at the door." Then I left the bay and went to the Pyxis.

After a few minutes, I had the naloxone diluted in a 10cc flush, 40 micrograms per cc. I had also labeled the syringe with that information. While I worked I noticed Dr. No giving a few ventilations every so often and looking a little perturbed. I wandered back to the bay to see how things were going. Dr. No looked up and asked if I had that Narcan with me. "Yes sir, I do. How much would you like to give?" We titrated in a small dose which restored the child's respiratory drive quite nicely.

I received a patient about that time so I was not part of the follow up. From my bay, it seemed the rest of recovery was unremarkable. Deedee notified the surgeon who spoke with the parents. I do not know what was said but trust the parents were adequately informed. We held the child for an extra hour past the usual discharge time, just to make sure he was okay. Also, the surgeon examined him prior to discharge.

Later that day I saw the head of anesthesia, Dr. Wise, and related the story to him. I praised Dr. Angel because I had confidence, knowing he had my back. Dr. Wise knew of Dr. No and his background. His only comment was, "I hate it when people dabble in pediatrics."

When I think of that cute little tow-head, I think of his parents who trusted him into our care. He is the most valuable thing in their world. They trusted us and yet a few little things combined that nearly ended in tragedy. We PACU nurses worked hard that day to validate their trust in us. My reward was seeing him go home with a popsicle in hand, and a story that I still cannot relate without tears.

A Patient to Remember

About azhiker96, BSN, RN