A
Shift in the Life — The Ongoing Story of a Critical Care
Nurse
“The
Dead Horse” -- Part 1 — by Matthew Nathan
Castens, RN
One of
my least favorite jobs in nursing is working as charge nurse.
As charge nurse for the shift, I have to know quite a bit
about each patient as I act as a resource for all of the staff.
This is the part I like. The part I don't like is working
with the staffing office and supervisor to arrange for any
admissions and finding the nurses to staff the next shift.
Unfortunately, this is most of the job of charge nurse.
On this
particular day working charge, I knew it would be a doozy.
As I sat down to report, I made sure that my cup of "Charge
Nurse" pills (extra strength Tylenol) was going to be handy.
The night shift was insane. They had a total of four critical
admissions when they really were only open for two. It wasn't
a disaster ... we frequently tell the supervisor that we can
take less than we really can. Now, though, all sixteen of
our beds were full and we had two heart surgeries planned
for the day, which meant that two patients would either have
to transfer out or die. I knew one would be going home the
easy way. From report it sounded like another would be going
"home" the hard way.
Bette
(names have been changed to protect confidentiality)was in
her mid-60s and very sick. No one was quite sure how sick,
unfortunately, because her family told conflicting health
histories and spoke minimal english. Our interpreter was able
to help somewhat, but couldn't be around full time.
Apparently
her son came home and found her unresponsive. He called 911.
When the paramedics arrived, they hooked her up to the heart
monitor and saw that she was in a wide-complex tachycardia.
This means that the electrical system of the heart was working
erratically and the muscle of the heart wasn't able to pump
the blood as efficiently as usual. This is what caused her
unconsciousness -- and her blood pressure of 50/20. In all
honesty, she should have been allowed to die right there.
Unfortunately, that was neither an option or the family's
wish.
The paramedics
tried to shock the rhythm into something more regular without
success. She was breathing on her own and well enough that
they didn't have to put in a breathing tube. They did manage
to get in a tiny peripheral IV and give her some fluid to
bring her blood pressure up by the time they arrived in the
emergency department.
Once in
the E.D., the code team took over. They also chose not to
put in the breathing tube and instead hooked her up to a BiPap
machine, which is a non-invasive way of forcing air into the
lungs when a person takes a natural breath. The nurses in
emergency weren't able to get in another IV, so the IV Team
was called. These expert nurses also were unable to find any
access, so they doctors decided to put in a large IV in Bette's
neck to give her medications and fluid. They tried twice.
Once the IV catheter went into down her neck and into her
arm (dangerous), the second time it went up her neck toward
her brain (more dangerous). They chose not to try again.
The blood
work that was sent to the lab came back. Bette's potassium
level was 9.4, which was lethally higher than the normal high
of 5. Her creatinine, which measures kidney function was 9.7,
where it might normally be less than 1.7. Let me tell you
-- when those to values match, it's ALWAYS a bad sign. When
they match high, it's even worse. With the balance of her
electrolytes being so far off, the pH of her blood was around
7.2 (normal = 7.35-7.45). Again, a really bad sign. They put
in a urinary catheter, called report and had her transfered
to us.
No one
knows what went on in the emergency department that night.
I'm sure they were busy. They did call the nephrologist/intensivist
(kidney doctor)to have him meet her up on our unit. I can
tell you that when we get a patient that critical, we would
have been expecting her to be intubated and with a large,
central IV in place. When she arrived on our unit, the nurse
went immediately to work. The nephrologist had made arrangements
to have dialysis started to remove the high potassium level
and creatinine. The nurse pressed several times to have Bette
intubated to help with the low pH, but the doctor said that
it would be corrected by dialysis. He was right. It could
have been corrected by dialysis -- if dialysis could have
started right away. As it was, dialysis couldn't start for
a few hours.
Fortunately,
one of the trauma doctors was able to come in a place a PA
catheter. PA stands for pulmonary artery. This is a long catheter
that is inserted in the neck or chest and goes down through
the heart and into the main artery of the lungs. PA catheters
are used to measure various components of cardiac output to
let us know how well the heart is pumping. The numbers they
saw that night showed the whole story -- a combination of
septic and cardiogenic shock. Somehow an infection got into
Bette's bloodstream and caused her blood pressure to drop.
>From the lowered blood pressure, her kidneys shut down and
caused her potassium to rise. The combination of the low blood
pressure and toxin buildup caused part of her heart muscle
to die and go into a secondary shock. Bette was a very sick
woman.
Two medications,
dopamine and dobutamine were started to help her heart pump
more effectively. Unfortunately, the dobutatime also lowered
her blood pressure and had to be stopped. The dopamine caused
her heart to pump even faster, but at that point it was the
lesser of two evils.
The dialysis
team arrived and started the dialysis. With all of the fluid
that is removed during dialysis, it is easy for a patient's
blood pressure to lower quickly and dangerously. Bette, of
course, couldn't afford a lower blood pressure, so the dialysis
nurse had to constantly be removing fluid and replacing fluid
depending on Bette's status. A patient in cardiogenic shock
can't tolerate a lot of fluid, so Bette quickly went into
a flash pulmonary edema -- she was literally drowning in her
hospital bed because her heart couldn't move the fluid given
to her by the dialysis machine. Anesthesia was called and
the nurse anesthetist rushed in and placed a breathing tube
down Bette's throat and she was hooked up to a ventilator.
During
the course of the intubation, however, Bette vomited what
was horribly foul stool-smelling emesis. Another clue: she
probably had an infection in her gut that started this whole
thing. A tube was also placed up her nose and down into her
stomach to suck out anything else that might be there. Also
judging by what was suctioned out of the breathing tube, a
significant amount of emesis was in her lungs.
This would
inevitably cause her to go into Acute Respiratory Distress
Syndrome (ARDS), meaning that her lungs were so damaged that
it would be very difficult to get oxygen to her blood. The
nurse then also noticed that Bette had started oozing blood
out of her IV sites and where they had placed the naso-gastric
tube -- all signs of Disseminated Intravascular Coagulation
(DIC), a complication of sepsis. This meant that Bette's blood
would be clotting in her internal organs, but be super-thin
everywhere else. Another REALLY bad sign.
At this
point the doctors and nurse sat down with the family to explain
the situation. Bette was going to die unless a serious, bona
fide miracle happened quickly. They explained that while there
were still options that haven't been tried, the outlook was
grim. The family chose to continue.
Keep in
mind that all of this happened over night. I was getting report
at 7 am. This was the situation I was walking into as charge
nurse!
I have
very strong ideas about futile care. Our society has become
so enraptured with technology and improving health that we
have forgotten that death is a natural part of life. People
get old, get sick, and die -- that's the way it works! No
one has to like it, but everyone has to accept it. Certainly
there are many cases when our medical system can stop the
untimely death and improve a life circumstance. There are
also many cases when it can't. It's the cases where it is
obviously futile that make me mad. All we would be doing for
Bette was prolonging the inevitable and causing her misery
and pain. My rule as a nurse is that I will take a patient
like this once to get a feel for the whole situation. If I
feel like continuing care is unethical, I will refuse that
patient assignment from then on. Fortunately, my hospital
has a policy in place for exactly that situation. Also fortunate
was that due to my working charge and Bette's quickly deteriorating
condition, I wouldn't have to invoke that policy. We would
have to deal with the situation as it unfolded, however.
Little
did I know how much harder the shift would get for me and
the nurse assigned to take care of Bette. Not only would we
be kept running to keep up with her deteriorating condition,
but I would become referee for nurse and family conflicts
alike. More on those events next time....
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... Next
>>>
