Tuesday, September 18, 2007

"I just hurt all over! I feel like I'm going to die!"

Last week was a little rough at work - Friday was the pits. I had an incident with a patient in the wee hours of Saturday morning.

I didn't like the way it was handled.


Mr. Z is essentially a post-op Day #2 of a knee replacement. We've been having "issues" with his urine output - so PM shift inserts a Foley in him (around 2100 hrs). When I assess him at 2300 (that's when I pick him up from PM shift), he's alert, oriented, talking about his family and an otherwise pleasant gentleman. I see some clear urine in the Foley drainage bag - not much, but some. I figure it'll pick up soon.

While I was walking my rounds at the other end of the floor, I though I heard someone calling out for help. Part of me wanted to dismiss it saying "you're hearing things". But my gut thought otherwise ... and I respect what my gut tells me. Figuring it can't hurt to check; I quickly walk over to Z's room...

... where I find him half-naked, with his hips and legs (including that post-op knee!) off the bed and on the floor... and his upper body obeying the Law of Gravity by slowly inching its way downwards and towards the floor.

Dadgum it!

I do a mini-dash into his room, reach over across his bed, hook my elbows under his shoulder and hold him by his shoulders to prevent him from crashing onto the floor. Straining and grunting with effort (Mr. Z weighs about 200 lbs. I'm about 150. Right now, Mr. Z isn't co-operating and he isn't supporting his weight either i.e. he is "dead weight"). I quickly realize that I can't win this tug-of-war and with my knee, somehow manage to hit the call light button.

"May I help you?"
(with a strained voice) "It's Spook! I'm in room 80. I need some help here, NOW!"

That produces a determined response - I hear sprinting of shoes down the carpeted hall and a nurse and a tech burst into the room. They quickly recognize the gravity of the situation (no pun intended) and help me maneuver Mr. Z safely back into bed. Crisis (and not to mention the paperwork) averted - for now. Mr. Z claims he was trying to go to the bathroom to pee. I patient inform the patient that he has a Foley catheter and as such, he's already peeing and doesn't need to go to the bathroom. I emphasize the importance of calling us for any needs that he may have. He doesn't appear confused; he's still alert and oriented.

I check his Foley bag - there a little more urine in there than the last time I checked it. Not a whole lot more, but an increase no less. Just as a precaution, I do a bladder scan on him. The bladder scan is a nifty little ultra sound machine that lets us estimate how much urine is in the bladder. I repeat the scan thrice - each time, the machine bleats "000 ml". His bladder is essentially empty. Satisfied, I inform Mr. Z that because of the position of his urinary catheter and where it rests in his bladder (against his sphincter - the "valve" that controls voluntary urine flow) - he's going to have this "sensation" of being "full" and "needing to void". I tell him that this is normal and that he doesn't have to go to the bathroom - the catheter takes care of it for him. I once again, stress the need/importance of calling us for any needs he may have, make him comfortable and walk out. As a precaution, I douse the lights but leave the door open - just so I can hear better from his room.

I resume my rounds on my patients. I medicate as needed for pain, continue my assessments on my recent post-op patients (increase the O2 flow rate on one patient, irrigate an NG tube on another, do a wet-to-dry dressing change on a third patient), and get back to the nurses station to begin the arduous task of "chart checks" (night shift is assigned the duty of "chart checks" - essentially we go over a patient's chart and make sure everything is in order... that physician orders have been implemented/carried out, labs and other diagnostics have been ordered, check the ordered medications with the current one present on the Medication Administration Record {MAR} on the computer, note any changes in treatment plan for the oncoming shift etc.)

At Zero Dark Thirty [that's "Half past midnight" for you non-Army folks ;-)], the Tech (nursing assistant) comes and tells me that the patient is "quaking". She'd just done his vitals (vital signs) so I ask the obvious question:
"Well, is he co..."
But before I can finish she answers:
"No, he's not cold. His temp is 36.8. But Spook, his HR is 156. BP 156/80. Resp 34. Pulse ox was difficult to get since he was shaking and shivering like crazy but the probe told me 96% on room air. I put two extra blankets on him to warm him up before I came to see ya".

So I goes to see my patient. Mr. Z is in there quaking like a leaf in the wind. Despite my many attempts to gauge his pain, he constantly denies pain. And then I notice something queer - his arms are bent at the elbow and his hands are scrunched up to his chest. The hands are shaking violently, but his arms more or less lie in the same position. I ask Mr. Z to "extend" his arms at the elbow (i.e. straighten 'em out). He says "I can't"

You can't? Or you won't?

So I try to straighten 'em out. I have to apply a good bit of effort to do so! His arms seem to be "locked" in position - I am able to straighten 'em out, but boy, I really had to TRY! That concerns me - if I was less informed, I would jump and say "Tetany!" but I notice that his other muscles don't seem to be affected. His legs are mostly fine, his breathing... while fast, doesn't seem to be impaired. His heart sounds fast as well... but I can't detect an anomaly right away. To be on the safe side, I do a quick Neuro assessment (fearing a stroke - his BP and age certainly put him at risk for it) - but the neuro assessment check out ok too.

Now I'm puzzled - but at the same time, more "worried". My "gut" tells me "something's up buddy".

I look down at his Foley drainage bag - hmmmm, no real change in urine output. Actually, come to think of it, the output looks no different at all! I walk over to the store room; pick up a bottle of sterile saline, a piston pump and a drainage tray. Donning gloves, I proceed to "irrigate" the patient's Foley (disconnect drainage bag from catheter. Instill 30 cc of saline into bladder. Allow to drain. Repeat as desired). I notice that my irrigation brings about bloody urine with LOTS of clots. That is unexpected. I irrigate as much as I can (for over 20 minutes) and dislodge plenty of clots in the process. Finally, the urine starts clearing up. I stop irrigating and reattach the drainage bag.

Now what smartass?

And then, it hits me - patient is allergic to latex. Evening shift has somehow overlooked this fact and has installed a Foley which has Latex in it (as opposed to the silicone we use in such cases) - could this be the cause of bloody urine? Possibly, but if patient was allergic to latex - shouldn't I be seeing an anaphylactic/systemic reaction? What I'm seeing is not an anaphylactic reaction - but I'm hesitant to rule out a systemic reaction.

So, trusting my "gut" and for no real justifiable reason, I rouse the tech and tell her to get me a Data scope and monitor leads. I proceed to place Mr. Z on a limited, 3-lead ECG set up.

Time: 0137

Right away, I notice something "awkward". The monitor doesn't reveal anything earth-shattering or "critical" - but all the same, it looks "different". I'm uneasy - I know the patient has some cardiac history - but nothing significant. And yet, if I filter out his obvious tachycardia - his EKG still doesn't "look right" to me. Acting on my own initiative, I page RT (Respiratory Therapy) and have 'em come up and do a 12 lead EKG for me (on night shift, RT does all the 12 leads in the hospital). While RT is doing this, I double check the chart and make sure pt. has blood transfusion consent form signed and call Lab to verify is Mr. Z has been "Typed and Screened" (a procedure that tests a patient's blood and matches to his/her exact blood type). I tell lab I might need at least 2 units of PRBC (Packed Red Blood Cells).

Then, I page the Hospitalist (Hospitalists are Internal Medicine specialists who are assigned to patients who don't have a Primary Physician or have Primary Physician who is out of town or have no privileges at the hospital). I give her the full report and state my concerns. She says she'll be up soon.

10 minutes later, Hospitalist is on floor. By this time, RT has completed the 12 lead EKG and has printed a detailed strip. We go over patient's chart together, and I outline in detail my concerns as well as recent vital signs and patient behavior. Hospitalist goes in to observe patient.

10 minutes later, she returns. Orders are written:
Stat (meaning "immediate") Cardiac Enzymes (typically Troponin and CKMBs). Repeat in 6 hours. Call results of lab tests to Hospitalist.

"You think Mr. Z has had a heart attack?"
"Most likely, Spook. I'm not sure yet. He doesn't seem to be a typical heart attack patient; even his EKG seems to be non-critical. But I agree with your assessment - I'm also 'uneasy' over the way the patient is presenting. Gimme a call as soon as the lab values are back. And makes sure he is Typed and Screened."
"Already done Doc! I'll call you with the results"

I call Lab and tell them to send someone up pronto to draw the requested labs. I go in to check my patient - and while I'm assessing him, he utters the cardinal words - "Nurse. I don't know... but I just don't feel good.

"I just hurt all over! I feel like I'm going to die".

Hellloooo! "Mayday" call here!

I've learned to recognize and respect the "feeling of Doom" my patients sometimes tell me about. While my patient isn't exhibiting any of the "classical" heart trouble/attack "symptoms" of chest pain (often radiating), shortness of breath (while he is breathing fast, he doesn't complain of feeling out of breath) and an altered EKG - I'm still worried. His last comment of "I feel like I'm going to die" coupled with the Hospitalist's 'fear' just makes the case.

I look down to peek at the Foley drainage bag - no real out put since the last time I checked it. As I walk back to the nurse's station to check on the stat labs as ordered before, I tell the Tech to do a bladder scan on Mr. Z. The labs aren't awful but they don't look good either.. Both his Troponin and CKMB reveal a possible muscle injury. At about the same time, the Tech comes back to me and reports with wide eyes and the patient has over 900 cc in his bladder. I page the Hospitalist and tell her that lab results are back. She thanks me for the information and advises me to keep monitoring the patient.

I have 6 other patient's to attend to. Some have been calling out for over 20 minutes. It's 6 of one or half a dozen of the other. I request a peer, a nurse who works the float pool now... but who used to work ICU and actually used to be the Director of the ICU 6 years ago to go assess Mr. Z and the lack/low urine output. She declares that she is going to pull out the current catheter and try replacing it with a latex free silicone one.

I get busy attending to the needs of my other 6 patients. Some need pain medication. Some need anti-nausea medication. Some need to be repositioned in bed. I help the Tech with the ones who need help getting to the bathroom.

Time: 0330

My peer (the former ICU director) informs me of her inability to get a catheter into Mr. Z. She tried the three smallest catheters we have on the floor and she couldn't get in. Now, she's been an ICU nurse for over 15 years and has years of nursing experience before that. She looked me straight in the eye and said:

"Spook. You need to get him transferred off the floor, NOW. He needs critical care - and we can't give it to him on this floor." She'd checked his bladder residual via Bladder Scan after her last failed attempt to insert a catheter in him and it'd come back as over 1100 cc.

I swore under my breath and literally assaulted the phone. I called the Cardiologist on call and advised her of the situation. She asked me a dozen questions to which I responded the best I could with the information I had. She said she'd be on site within the hour.

Next, I called the Urologist on call. He rattled off a list of items he wanted readied and said he'd be on site within the hour as well.

Next, I called the Hospitalist. Informed her of the lab results.

"Oh wow! Mr. Z is having a heart attack. Please STAT page Cardiology. I'll come up soon to assess patient. Also start patient on prophylactic antibiotics - Zosyn prophylactic dosage IV every 6 hours and Vancomycin daily standard dosage IV every day per Hospitalist standing orders. Inform Cardio...."
(Cutting her off) "I've already talked to Dr. DO for Cardiology and Dr. NS for Urology and advised them both of the urgency of the situation. They will both be here within the hour."
"Oh good! Please monitor patient carefully. I'll be up in a few minutes.
"Will do, Doc!"

Next, I call the House Supe (House Supervisor) TA (a Registered Nurse) and let her know of the meltdown on the floor. She lets out a silent groan and asks me "what's the plan?"
"DO and NS are coming over to work on the patient. I suspect he will soon be moved to the Cath Lab. TA, I could really use some help. I'm juggling 7 patients here."
"Ok, I'll be up soon and I'll bring along EM from ICU"

EM is an ICU nurse. ICU nurses, along with RT respond to a "rapid response" on the floors. Though I have not "called" a Rapid Response on the patient - given the situation, it's understood that this is warranted. RT is already on the floor.
I've worked with EM and TA before - they're swell. As soon as I'm done talking to them, I call the Cardiologist again and request that the patient be transferred down to the ICU or the Cath Lab - reason being that folks down there are more attuned to crises of these sort, have more training and also more "leeway" in terms of physician orders to deal with it. Cardiologist refused - stating that she needs to assess patient before allowing transfer because she didn't know if patient needed to go to Cath Lab right away or if transfer to ICU would be appropriate for the moment. I could understand her PoV... but at the same time, I cursed it. Because I knew that the minute she would walk onto the floor, she'd ask me a million and half questions - and a lot of them I would not be answer because I simply didn't have the authority to order those tests or carry out those interventions. A nurse in the ICU or Cath Lab could have - but I couldn't. I lacked the "standing orders" protocol and authority.

With the calls done, I decide to prep the patient's chart - transfer to a "different unit" requires some amount of paperwork - thanks to "The Joint Commission" (cue reverential music). Mostly unnecessary BS that actually eats up my (and more importantly the patient's) vital time... but who am I, a lowly staff nurse on the floor to argue with the rules laid down by the demi-gods in JCAHO?

While I'm prepping the chart, I tell the Tech to get me a fresh set of vital signs on the patient. She responds and promptly reports the news: HR: 110, BP: 150/100, resp rate: 28, Pulse ox: 90%

Not good. I grit my teeth...

Time: 0415

... and as I'm doing do, the Urologist walks onto the floor. I ask my fellow nurse on the floor (and the tech) to cover my side of the floor while I assisted the Urologist.

Then, I gather the equipment and walk into the patient's room to assist. Urologist administers local anesthesia and proceeds to brutally ream out the man's urethra (penis). But he does get a good sized latex free, silicone catheter into him and immediately drains over 1100 cc of urine from Mr. Z's bladder. Near the end of this procedure, the House Supe and the ICU nurse arrive on the floor.

I feel a degree of relief - I have back up now. The ICU nurse immediately proceeds to take a quick report on the patient from me, and then says "Spook, I know you have 6 other patients to look after. Take care of them; I've got Mr. Z under control here". She proceeds to diligently monitor the patient with help from the House Supe. I place a call to the patient's wife and inform her of the events. She is distraught, as expected, but informs me that she'll be over as soon as she can wake up her son to take her to the Hospital (she's disabled).

Time 0445:

The Cardiologist walks onto the floor. Converses briefly with the Urology. Then turns to me and begins a barrage of questions - many of which I am unable to answer. EM, the ICU nurse steps up and says "Well, it's hard for staff nurses on a regular floor to do these things. They usually have more than 6 patients to worry about and their freedom of action is restricted by the lack of standing orders in case of emergencies. Do you still want to move the patient off the floor?"

Cardiologist softens her stance a bit. "No, I still have to see the patient. Let's go".
I turn to EM and she winks at me with a smile before accompanying Cardiologist to see the patient. I'm grateful - while I do feel like a blubbering idiot for not knowing everything the Cardiologist asked of me, EM showed that it wasn't entirely my fault. That helps... a little.

Meanwhile, it's almost 0515. Time for I/O, morning meds, blood glucose checks and insulin administration, changing IV bags and PCA pumps, helping patients to the bathroom.

While all that is going on, I'm frequently interrupted by the nurses/doctors hovering over Mr. Z. Pharmacy has sent up the Abx ordered by the Hospitalist for Mr. Z. I hand them over to EM.
Then it occurs to me that I have not charted on Mr. Z for a while now and that in all possibility, he is going to be transferred off the floor! I hurriedly jot down the Physician orders I've recd. over night for Mr. Z and then sign them off. Also, as a courtesy, I print of a Med Reconciliation List and other needed documents [a "The Joint Commission" (cue reverential music) requirement] and hurriedly place them in the chart.

By the time AM shift arrives on the floor - Mr. Z has mostly been stabilized and is just awaiting swift transfer to the Cath Lab. I'm tying up loose ends and paperwork... while simultaneously trying to deal with my 6 other patients - who are all due morning antibiotics, I/O, pain medication and toileting. Cath Lab folks are now in Mr. Z's room - TA and EM will handle transport for me (standard protocol)... and I'm grateful for that. The Cardiologist has managed to obtain consent for possible procedures. Lab has blood work confirmed.

Charge nurse walks onto floor and observes flurry of activity and just shakes her head.
I am unable to tape report for the next shift and thus must give verbal. Some of the nurses on AM shift roll their eyes, as if stating "He hasn't taped report yet! That is so inconvenient!!" Some nurses on AM shift instantly piss me off by asking inane, dumbass questions they don't need to ask (because they can look it up for themselves). One of the nurses on AM shift grouses over the fact that I haven't discontinued a Foley catheter on a patient - I thought it was incredibly rude, condescending and short sighted on her behalf and I'm tempted to tell her that I had "7 patients all to myself with one of them having an active heart attack" but I bite my tongue and say nothing. It's pointless - day shift has never had to deal with short staffing.

I finish report just as they are wheeling Mr. Z off the floor. I thank TA and EM again for their help and assistance - truly, I wouldn't have been able to do 1/10th of what I did without their help.

I haven't eaten in over 14 hours. I haven't even taken a bathroom break to piss in my entire shift. I quietly go and relieve myself, then sit down to chart.
After 3 hours of charting at the end of my shift, I tiredly walk to the elevators, punch out and leave for home.
Fighting sleep the entire way, I drive home in one piece and collapse in bed.

Only for 3 hours though. For I'm scheduled back for that night.

Mr. Z ended up getting a quadruple bypass surgery. He's still in the Cardio Vascular Care Unit as I type this....


Jaime said...

Just...WOW...I can't even imagine! I'm glad the gent came out of this alright but winced when I read about the foley, eek!

I don't know how you do it but I can say if I were in the hospital post surgery I'd want someone like you watching over me. =)

NocturnalRN said...

Man that sucks! I hate nights like this. I especially hate that us takes FOREVER to get the patient off the floor. It takes up so much time and it is impossible to deal with a situation and properly look after the other patients we are responsible. This sort of thing has happened to me a lot. The added bonus is when one of my other patients berrate me for not coming to their room in a timely manner for something petty. Like they think I'm out reading magazines or taking a nap or something. You were lucky you had good help and that one taking up for you. Hang in there and may you have several good shifts in a row to make up for this one!