Question for CCU or ICU nurses

ChocoholicRN · Mar 5, 2008

I've never worked in an ICU or CCU, but here's what I think would happen to the person in your story: If someone woke up after being in a coma (thats what i'm assuming happened to the person in your story) they probably would not know they were in a hospital and would not know where the call bell was or what the button did. If anything, I would imagine the person to be confused, possibly try to fight the breathing tube. With this, the nurses would notice significant vital sign changes on the monitor (increased HR, BP, etc) and rush in to check on the patient. I'm not sure what the patient themself would see in the room, but I really don't think they would wake up and think "look at that, i'm in the hospital, let me call for the nurse so i can find out what happened." Just my :twocents:

mawwriter · Mar 5, 2008

This is excellent, jerzytech! Just the type of thing I was looking for. I'm sure the scene as I have it now would have looked pretty silly to all of you experts. Thank you very much.

Anybody closer to this type of work have any input on protocol for a patient who wakes up from a coma spanning weeks or months? Do you ask them standard questions? Immediately try to remove the breathing tube, or try to calm them if they're fighting it?

mawwriter · Mar 5, 2008

jerzytech, it wasn't quite as simple as "Well, gee, here's a red button." But that was pretty funny.

Here is the scene so far, without any expert input (I was guessing about the nurse's actions) :

Now she was lying on her back, dull pain running through her chest and an unfamiliar fullness in her mouth and throat. She opened her eyes and looked down to see what was in her mouth. A breathing tube. Tiled drop ceiling loomed overhead. She recognized the sterile, unnatural smell. Hospital.

Carefully, she turned her head to the left. A door stood between two windows, drapes wide open to reveal a white hallway. To the right, painted white drywall stared back. In front of her was the same, except for a sign and a painting of a flowery field.

The flowers were yellow and orange and comprised the bottom half of the painting. Across the middle was a line of trees of varying heights, a white farmhouse among them. In the distance stood a mountain range of rolling hills. Above it all was a blue sky with soft white clouds.

The sign below it read, "In case of emergency, press red call button."

Having no idea what was going on constituted an emergency. Why had Jeff attacked her? Had he said there had been other victims? Was Glenda dead? Recalling events from that night was like looking through thick fog.

Beside her on the bed, Bernie found a gray cylinder that looked like an ink pen fattened up for slaughter, with a red button on top and a wire leading out its other end. She splayed her fingers out to reach it and pulled it within thumb's reach. She pushed the red button.

She lay there thinking that she should have pushed a big red button a long time ago. Scared that nobody would answer, instead she had languished in her grief and lingered in a damaging environment. Leaving behind all that she had known, the good and the bad, had never seemed possible.

Then came Shonda. Where was she? Bernie pushed the red button again.

The door opened and in rushed a young woman, maybe 30 years old, with dirty blonde hair cropped level with her jawline. She wore dark green scrubs and white SAS shoes. A stethoscope draped over her neck.

She flashed Bernie a wide, welcoming smile. "Well, look who's awake," she said. Clumps of mascara clung to her eyelashes and her rouge verged on clown makeup.

Bernie tried to speak, but no sound came out.

"Don't try to talk too much yet. We'll see about getting that breathing tube out and getting you some water. That should help."

The young woman bustled about checking monitors and charts. Despite all the technology in the room, she gently turned Bernie's arm palm-up and laid two fingers on her wrist to check her pulse. She pulled a blood pressure cuff from a drawer and strapped it around her upper arm, then rapidly squeezed the black bulb. The cuff tightened.

Her memory flashed back to Jeff's firm grip on her arm as she cocked it to throw a bottle at Glenda. He had been firm, but not malicious. Later, in her shack, although he had meant to kill her, he had not seemed angry. Instead, he was frighteningly calm as he worked to -- what had he said? To add her soul to his collection?

"Oh, my, you have goosebumps. Are you cold?" the nurse said.

Bernie slowly shook her head.

cardiacRN2006, ADN, RN · Mar 5, 2008

If she's in a coma for weeks and still on the vent, I would hope she'd be trached by now and sent to rehab. Her injuries should be healed by now as well.

Most people who "wake up' are quite confused. If my call light went off, and I went into the room my first response wouldn't be "look who's awake" it would be, "can you hear me, can you understand me, squeeze me hand, etc, etc"

I would want to know that they are in there. Then I'd give them the whole story about what happend to them, what day it is, how long they have been in the hospital, what their status is, etc.

mawwriter · Mar 5, 2008

CardiacRN2006 - Thanks for those details about what you would do!

This also helps me decide how long I'll have her in a coma, because this isn't a story about a long rehab process. This is part 10 of the story, BTW.

kurlykay · Mar 5, 2008

I agree with CardiacRN, If the patient is in a coma and on a vent we usually will trach them within a couple of weeks. As soon as they are trached (providing that we have "fixed" their other injuries) we send them out of the hospital to another type of facitlity depending on the level of care they need.

If a patient who can been in a coma wakes up and they are on the vent, they will usually try to fight the vent. This would make the ventilator alarm and the RN would go into the room to check on the patient. Sometimes we will also see changes in vital signs (such as an increased heart rate) because the pateint is usually scared. I also agree with the other posts that they patient would be confused and have no memory of what has been going on so pushing the call light would not be believable. If I was the nurse, I would explain to the patient that they are in the hospital and have them nod their head to some simple questions (like are you in pain) so I can get an idea of what their mental status is like.

ukstudent · Mar 5, 2008

We put trachs and pegs in pt's around the two week mark. The first thing done with a change in mental status would be a full neuro check. Light shone into the eyes to check pupil response. They would be asked to move their extremities. Squeeze and then release on command.

Unlike in movies and book's most people do not just wake up. Reality would probably make for a boring read. It is a lot of basic nursing care of turning the pt every 2 hours, suctioning secretions form the lungs, mouth care. Have fun with your story.

RNperdiem, RN · Mar 5, 2008

I agree with the others. Often a patient totally wigs out when waking up on a ventilator. The nurse would verbally attempt to calm the patient down while calling for some sedation.

Blee O'Myacin, BSN, RN · Mar 6, 2008

The patients that I've had that "woke up" did so slowly and almost always try to extubate themselves. You might want to add soft wrist restraints to the mix and have the patient fight the vent - the alarming of the monitors/vent would have the nurses running in. (Makes for more drama, and more realistic if the patient doesn't just calmly press a call light) - besides, a patient in a coma doesn't usually have a call light in reach. Intentions are good, but in reality, it gets moved out of reach during those q2h turns, complete bed changes - etc.

In my experience - intubated patients need heavy sedation that is gradually reduced as a person is weaned from the ventilator. Someone being completely unresponsive without medical sedation suddenly having full consciousness and the ability to press a call light is unlikely.

Blee

mawwriter · Mar 6, 2008

Thanks to all who posted replies. I was ready to publish (I'm posting it online as I write it, first draft), so I quickly took all your input and re-worked this chapter. Here it stands:

Bernie felt she was being carried, cradled like a baby. Warm air hit her face in short, rhythmic bursts-is that someone breathing?-but she couldn't open her eyes. Cold and pain wracked her body, and then all feeling disappeared.

-----

Now she was lying on her back, dull pain in her chest and an unfamiliar fullness in her mouth and throat. She felt like she was suffocating.

Her arms felt like lead, and she realized when she tried to lift them that her wrists were restrained. Unable to draw her own breath, she broke out in sweat and her heart raced. She arched her back and then felt restraints on her ankles, too.

She tried to shout, "Help!" but got nothing, not even a hoorifice yell. Her hearing aids were not in.

A nurse rushed over with a syringe and injected it into a tube leading into an IV. Bernie's vision faded and everything went dark.

-----

A dull ache came from the base of her throat. Tiled drop ceiling loomed overhead. The unnatural smell of hospital washed over her, but when she tried to hold her breath, somehow she was still breathing.

Where am I? What's going on?

With a hazy memory of an earlier episode, she tried to move and felt the tug of soft straps lashing her arms and legs to the bed. Her mind raced with questions. Why did Jeff attack me? Is Glenda dead? Where is Shonda?

She sobbed and felt her heart pounding.

Suddenly three nurses surrounded her. On all their faces she saw surprise, delight, concern, and determination. They were working quickly, apparently toward a common goal. One said more than the others and seemed to be in charge, but the only thing Bernie could read from her lips was, "bee pee."

A nurse held up a syringe, pushed the air bubbles out, and turned her back to Bernie. No, not again. Her eyes fluttered closed.

-----

Bernie woke up uncomfortable and confused. She didn't know how much had been a dream. Did Jeff stab me? Despite her questions and the inability to so much as scratch her own nose, she staved off panic.

She couldn't remember the medical term, but she knew there was a breathing tube inserted directly into her neck. Her mind pulled up George Clooney on "ER" blowing into the end of Bic pen he had just inserted into a boy's neck.

She licked her lips. It had never felt so good.

Where is everybody? "Hello?" she croaked.

In rushed a young woman, maybe 30 years old, with dirty blonde hair cropped level with her jawline. She wore dark green scrubs and white SAS shoes. A stethoscope draped over her neck.

She flashed Bernie a wide, welcoming smile. Clumps of mascara clung to her eyelashes and her rouge verged on clown makeup. Bernie read "Ms. Maven," from her lips, but the rest was gibberish, so she just stared at her and tried to pick out her words.

The nurse grabbed her hand and started patting it. "Ms. Maven," and then more words Bernie could not decipher. She put her hand under Bernie's and pooched her lips out for what must have been a meaningful word, but looked silly in silence. Bernie just stared as the woman's smile faded.

Bernie said, "Deaf," or what she hoped sounded like it.

Relief swept over the nurse's face. She walked over to a drawer and

pulled out a zippered plastic bag that held Bernie's hearing aids. She flipped the tiny switch on each and carefully inserted them into Bernie's ears, then backed up so Bernie could see her face.

It was faint, but Bernie heard ventilator as it inhaled.

"I forgot about those. Can you hear me?" she said.

Bernie nodded slightly and tried to speak, but no sound came out.

"Don't try to talk too much yet. We'll see about unhooking the vent from that tracheostomy and getting you some water. That should help. Now, can you squeeze my hand?"

Bernie did.

"Good. What is one plus one?"

Bernie folded down all but two fingers on her right hand.

"Very good. You can hear me and you seem to understand me. I'm sure you have a million questions right now, but I can only tell you what I know about you medically. Do you want to here it?"

Bernie nodded.

"You were stabbed, and the knife hit a lung and an artery. You lost a lot of blood, but the surgeons were able to help. You've been out for about a month, and it's good to finally see your eyes."

The young woman bustled about checking monitors and charts. Despite all the technology in the room, she gently turned Bernie's arm palm-up and laid two fingers on her wrist to check her pulse. She pulled a blood pressure cuff from a drawer and strapped it around her upper arm, then rapidly squeezed the black bulb. The cuff tightened.

Bernie's memory flashed back to Jeff's strong grip on her arm as she cocked it to throw a bottle at Glenda. He had been firm, but not malicious. Later, in her shack, although he had meant to kill her, he had not seemed angry. Instead, he was frighteningly calm as he worked to-what had he said? To add her soul to his collection?

"Oh, you have goosebumps. Are you cold?" the nurse said.

Bernie slowly shook her head. Recalling anything right now was like looking through thick fog. She heard the rip of Velcro as the nurse released the blood pressure cuff.

She thought she could move enough to write. She made a pinch gesture and mimed handwriting motion. The nurse stepped back over to the drawers.

Carefully, Bernie turned her head to the left. A door stood between two windows, drapes wide open to reveal a white hallway. To the right, painted white drywall stared back. In front of her was the same, except for a sign and a painting of a flowery field.

The flowers were yellow and orange and comprised the bottom half of the painting. Across the middle was a line of trees of varying heights, a white farmhouse among them. In the distance stood a mountain range of rolling hills. Above it all was a blue sky with soft white clouds.

The sign below it read, "In case of emergency, press red call button."

She lay there thinking that she should have pushed a big red button a long time ago. Scared that nobody would answer, instead she had languished in her grief and lingered in a damaging environment. Leaving behind all that she had known, the good and the bad, had never seemed possible.

Then came Shonda. Where is she?

"Here's that pen and paper. That's what you wanted, right?"

Bernie nodded and opened her fingers to accept the pen. The nurse gently placed it in her hand and set down a pad of paper bearing the name University of Arkansas for Medical Sciences.

StacieRN, RN · Mar 6, 2008

Very nice imagery. A few things though: A newly trached pt has to be taught to speak. And they can't speak while hooked to the ventilator. For speech to happen, air must move over the vocal cords. While connected to the vent, air exits before that happens. The vent will be unhooked (after a breathing trial) and the end of the trach tube will be capped or the pt will be taught to cover the end of the tube with a finger when speaking.

Next: if this patient has been in a coma long enough to be trached, she will NOT have restraints on. They would be unnecessary. She was comatose - i.e. not trying to pull tubes out. So upon awakening she would probably reach up and pull the vent tubing away from the trach in confusion. Thus setting off the vent alarms and bringing your nurse running to reattach it.

I do agree that the nurse would do pupil checks almost immediately after re-attaching the vent (usually while updating the pt on her condition).