A
Shift in the Life — The Ongoing Story of a Critical Care
Nurse
“My Most Memorable Case” - by
Matthew Nathan Castens, RN
Andy [names
have been changed to protect confidentiality] was in bad shape.
A young man (at least for our standard population), Andy was
48 years old, a smoker, never exercised, and had a strong
family history of coronary artery disease, which is why he
had bypass surgery a couple of weeks before. He was young,
but it seemed that our bypass patients had been getting younger.
Call it the curse of McDonalds’, I swear, fast food will
be the death of America.
Before
our patients are discharged, they are given explicit instructions
on how to care for the incisions in their chest and legs:
while showering, use a clean washcloth and antibacterial soap
to wash the incisions and prevent infection. They are also
told explicitly not to lift more than ten pounds for several
weeks to allow the freshly cut and repaired breastbone to
heal.
Andy didn’t
listen to the nurses. He decided to do one or more of the
things we told him not to do and he was back in the hospital.
This time he was worse. Andy had developed a sternal wound
infection in his chest, became septic (the infection got into
his blood system and was adversely affecting every system
of his body) and had a sternectomy (his breastbone was removed
— permanently).
Now he
was my patient again. I had been his nurse when he came back
from his first surgery and again for a couple of nights this
admission. He was still on the ventilator, but I was pleased
to see that we had added a propofol drip. (Propofol is an
anesthetic agent that is sometimes used to keep patients asleep
while they are on a ventilator.) This would keep him comfortable
and relaxed — important because his chest was never closed
after his sternectomy. That’s right, his chest was wide
open. Looking into the huge hole under his neck, a nurse could
see his heart beating in the pericardial sac, his lungs inflating
and deflating with each breath of the ventilator, and all
the other landmarks learned four years before in anatomy class.
I was fascinated. I had seen this sort of thing before, but
I had only been an RN for a year. I was thrilled that the
nurses in the unit thought I was ready to handle such a complex
case. I also knew that they wouldn't give me a patient this
complicated without backup. Several of my mentors were working
with me that night and I knew they wouldn't let Andy or me
sink.
The shift
started as I had expected. Because his case was so complex,
Andy was my only patient. My first duty after getting everything
organized for the shift was to change the packing in his chest.
Andy’s wound had gotten so infected that, along with
the intravenous antibiotics that he received around the clock,
his chest was packed with sterile sponges soaked in an antibiotic
solution. Not only would this fight the infection, but the
process would also debride, or remove, the necrotic (dead)
tissue from his chest cavity. I was very careful as I removed
the old packing. Sometimes the sponges would dry and get sort
of bonded to the tissue. If I pulled to hard on these sponges,
I could cause some damage in Andy’s chest. All of the
sponges came out nicely and I took a moment to marvel at the
human body as I watch Andy’s heart and lungs do their
jobs. The new wet sponges were packed in tight and I moved
on to the rest of the night’s work.
I carefully
shined a light into Andy’s pupils to see if they would
react. They did. Because he was under anesthesia and completely
sedated, I knew he wouldn't wake up for this brief discomfort.
I would save the rest of my neurological assessment for the
very end so I would have complete control when the time came.
I listened to his abdomen and heard faint bowel sounds, a
good sign. I listened to his heart as well as I could under
the circumstances and didn't hear anything I wasn't expecting.
His pulses were difficult to locate, but this was because
he was on intravenous medications called Levophed and dopamine,
which helped keep his blood pressure stable; unfortunately,
they also greatly constricted his peripheral circulation and
make his pulses hard to find. I got some assistance from my
coworkers to get Andy carefully turned. I listened to his
lungs from the back and carefully examined his skin to make
sure there was no breakdown. He also had a bag attached to
his rectum to keep the stool from harming his skin. He was
on a tube-feeding machine, which provided all the nutrients
he needed, but also gave him horrible diarrhea. I gave him
a back rub to help his comfort and circulation. When I had
finished the assessment he was placed onto his back. Now for
the neurological exam.
The nice
thing about propofol is that it is easily controlled and very
fast acting. Periodic neurological exams needed to be performed,
because Andy’s state was so critical; with someone so
sick, there’s always a small risk of stroke. I turned
the rate of the propofol infusion down slightly. After about
a minute, I could tell that he was awakening from the anesthesia.
After about two minutes I did my exam. Normally I would have
checked his orientation but since anyone would be completely
disoriented after being so heavily sedated for so long I simply
told him what was going on, -Andy, you're in the hospital.
It’s the middle of the night — about one in the
morning. My name’s Matt and I’m your nurse tonight.
I need to finish looking you over and I’ll let you go
back to sleep." The rest of the neurological exam went pretty
much as I expected. He moved all of his extremities spontaneously
and definitely pulled away from the slight pain I inflicted
on his nail beds but he didn't follow any commands. I turned
up the propofol and waited for him to fall back under its
spell. As he fell asleep, he coughed.
I moved
by his head to make some final adjustments to the monitor.
I like my alarms and features set just so. When I was done,
I glanced down at Andy’s neck. He was bleeding from somewhere.
I thought it was from the big IV catheter in his neck, sometimes
they ooze, but it wasn’t. Interesting. I pulled back
the sheet and became wide-eyed. There, in the middle of the
new, clean dressing was a deck-of-cards-sized area of bright
red blood growing very fast! I new I was in trouble. I moved
to the door of the room, saw my mentor sitting at the nurse’s
station: “Um, Sandy??” Apparently the tone of my
voice was enough, because immediately three nurses were by
my side and talking quickly.
The twenty
minutes that followed seemed like two. I was busy holding
pressure on Andy’s chest to keep the blood from squirting
out of the sides — not so heavy as to stop is heart,
though. John was acting as a runner between our unit and the
blood bank to bring six units of blood at a time. Sandy was
running the show, as well as the rapid infuser that would
transfuse a unit of blood in thirty seconds and a liter of
saline in ninety. Linda, the charge nurse, was on the phone
to surgery to warn them, and to the surgeon, Dr. King, to
have him rush to the hospital. Two orderlies from the OR arrived
and we rushed Andy downstairs with me sitting on the bed holding
pressure on his chest.
I didn't
know what to think. Sandy reassured me that I had done everything
as I was supposed to. An hour later, when Andy returned from
surgery we learned what had happened: when he coughed, Andy
pulled one of the bypass grafts away from his aorta, the main
artery from the heart. If I hadn't noticed the blood, he would
have been dead within a minute.
Over the
next two weeks, Andy’s chest was closed and he was given
a tracheotomy so that he could stay on the ventilator long
term. We were able to wean off the propofol so he could interact
with his wife as much as possible. Physical therapy came by
daily to keep his muscles in shape as much as possible while
he stayed in bed, and we were able to get him up to a special
chair a couple of times per day. We discharged him to a long-term
hospital that specialized in taking patients on ventilators.
We felt like failures, because we weren't able to help him
recover fully. At the long-term hospital he would most likely
develop numerous other highly resistant infections and die
in isolation.
Seven
months later, Andy returned. More accurately, he walked into
our unit along with his wife. They brought three shopping
bags full of chocolate, one for each shift. He looked weak
and thin, but he moved under his own power and thanked every
nurse he could find for saving his life.
About
Matt
Matthew
Nathan Castens got his start in 1994 as a nursing assistant
in intensive care, coronary care, and emergency.˛˛He graduated
from Normandale Community College in Bloomington, Minnesota
in May of 1999 with his Associate’s Degree in Nursing.
Since
January of 2000, he has been on staff as a registered nurse
in the Cardiovascular Intensive Care Unit at North Memorial
Medical Center in Robbinsdale, Minnesota, one of the first
ever units to promote the single-unit stay environment for
open-heart recovery. He also works as a flight nurse for ALS
AeroCare, based in the Twin Cities.
Matt
specializes in the recovery of open heart surgery patients,
trans-myocardial revascularization, and the care of myocardial
infarction, CHF, and pulmonary edema. He is also very familiar
with intra-aortic balloon pumps, dialysis, and continuous
renal replacement therapies.˛˛Matt is a member of the American
Association of Critical Care Nurses.
Matt
is experienced in working with a wide population of patients,
thanks to the availability of experiences in North Memorial's
Trauma/Neuro and Medical/Surgical ICUs. Visit Matt’s
own page at: The
ICU Answer Page! Or go directly to his ICU
Answer Forum...
Browse through his other articles. ...
