Sad but true

Night shift received a trauma last night. We start our shift an hour
before nursing so we can start our first round before breakfast and
before nursing comes in. It works out real well. Anyways, back to my
story.

We were in ct with this patient & the day er nurse came in to relieve
the night nurse.

Day nurse: do you want me to take over so you can leave?

Night nurse: no, I'm okay.

Day nurse: ok, good, I have some drug seekers to take care of.

Me: heehee

More advice

I went to do an ABG on room air followed by a DuoNeb tx on a 62/m. The.nurse was drawing labs and getting a history. He is a 100 pack year smoker with no medical history and no regular doctor. He said he hasn't needed a doctor before. He has been sob for a few days and today it
was bad enough to bring him to the er. Vitals are...hr 100, rr 20, spo2 on ra is 92%. I get the blood gas (on the first attempt, I want you to know) and the ph & pco2 are unremarkable, but the po2 is only 54. I went back to start his tx and his is surprisingly pretty clear, not diminished at all, like I had expected. When I was finished, I put him on a 4L nasal cannula.

Two hours later, the er calls me for another tx. The patient looked the same, still a little sob. Vitals are the same, however, this time I swear I hear some fluid in his lungs. Now the xray report is back...mild CHF, blunted costophrenic angles, blah, blah. This is at 1500 and now his is admitted (waiting for a bed) with tx ordered q4 & prn.

At 1730, I was giving a tx to the cutest kid (not an important detail of this story, but he really was cute) in the room next door to the above patient when I overhear Dr F asking him of he wants another tx. So, I peeked around the corner to see what's going on. The patient tells the doc that he does NOT want a tx right now.

As I'm listening to their conversation, I actually LOOK at the patient & see the following...

• An obvious increase in his work of breathing
• A heart rate of 135
• A respiratory rate of 40
• An spo2 of 88%

So, I asked Dr F if he wanted me to give him a tx anyways. I am shot down. Okaaaayyyy, you're the doctor and against my assessment and better judgement, I walked away.

But I couldn't get over his obvious decline so I turned back around to talk to the pt myself. In professional medical terms, he looked like shit. I told him that his tx is due at 1900, but he can have it early and he agrees, thank God, but it didn't help.

This tx did nothing for him, and now his lungs sound, horrible. He sounds like a washing machine, so I went to talk to his nurse. She kind of blew me off (what do I know, I'm 'just' an rt), but I was persistent and told her that be was going to end up intubated if this wasn't addressed. She said,"I wonder if he needs lasix"

You think? Wow! You are briliant.

She went to talk to Dr F and I went to the department to give report & go home.

Sure enough, not 5 minutes later, we are called for a stat abg. The night therapist went & I waited for him so I could see the results.

When he came in to run the blood, first thing out of his mouth is,"this guy looks like shit"

As soon as he put the blood in the machine, the er calls and wants to intubate him!!! I knew it!!! They sat on him all day & now he's being intubated!!!

So, like tired dayshifters, we left. So I'll update you on him next week when I go back to work.

So for my bit of advice...

CHF needs lasix, not albuterol/atrovent.

Thank you.

Word of advice

To the home 'nurse' who came today to see my/your patient...

Do NOT ambulate him on room air when he is requiring a NRB at rest.
That might be why he was dusky and slumped over in his wheelchair when
you were pushing him back to his room.

That might also explain why his respiratory rate is in the 40s.

But who am I? I'm just an RT.

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Eerie

I walked into a new patients room at 0800 to give him his first duoneb
of the day. He was not looking so good. He was sitting on the edge of
the bed, tripoding and pursed lip breathing. He hand were shaking real
bad so it was hard to get an accurate spo2. I also noticed that he had
some cankles going on. Instantly I think CHF. He looks a little dusky
so I take off his cannula and start up his treatment. His color
improves, his shaking subsides...generally looks a little better. Then
he tells me...

"I don't think I'm gonna make it today."

I reassure him and tell him that as soon as we get the fluid off of
him, he will feel better. My treatment is over, his vitals are stable,
so I tell him I'll see him in a few hours and leave.

Rapid response team to room 173. Rapid response
team to room 173. Rapid response team to room 173.

Shit!!! It's 0830. I just finished up his last treatment. Shit!!!

We walk in his room & he looks exactly the way he did when I first
walked in the room. He proceedes to tell us that he hasn't taken his
lasix in 7 days. Dr W happened to be around so he is there with us and
orders 80 of lasix. I slapped on another treatment just so everyone
will feel better, he gets his lasix, then I leave as they want to
start a foley.

Code blue room 173. Code blue room 173. Code
blue room 173.

Shit! Damn it! I looked at the clock. It's 1030.

We get in his room and start CPR. He is in PEA so I am doing
compressions, telling the er doc that he told me he wasn't going to
make it. He is intubate and I switch with the student. I see a rate
on the monitor, but of course, its just us. Someone brings in a
Doppler. Still no pulse. I resume compressions, look at the monitor
and am pleased with my efforts. Looks like vtach with a rate of 105.
Pretty effective. As I'm mentally patting myself on the
back...

Oooowwwwccccchhhhh!!!!

In the split second to took my hands off his chest, I saw his limbs fly up and realized his internal pacer/defibrilator had fired.

Ah damn, that hurt.

After 30 minutes if ACLS, the code was called.

Two things I learned from this...

1 - when a patient tells you he's gonna die...even if you don't think
so...pay attention.

2 - beware of those pesky implanted defibrilators. Everyone but you
will think its funny when you get shocked.

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Are you kidding me???

So the er call us down to look at a home vent, to make sure it is working. The patient was biba because her husband says the vent is not functioning properly. The vt is set at 600 and is only returning 150-200. There is an audible leak around her nasty, crusty trach which he said he changed this morning. He has a washcloth taped to her like a bib because her secretions are oozing from her stoma. We mess around with it and the leak is very positional.

Dr B — who I LOVE, because he isn’t afraid to tell us he doesn’t know what to do — asks for our opinion. We decided that she had out grown the trach and we should try to change out the 6 shiley and put in an 8. He has us walk him through the process and he does it beautifully. The leak is lessend and we have to explain to the husband about SIMV and how the vt will vary and blah blah blah. He wants us to give him spare trachs in the new size.

During all of this chaos, he calls us to suction, then when we get there, he is doing it himself. I look at the chart and guess what??? No pcp and no pulmonologist. Are you kidding me??? How can you have ALS and be vented and no doctor???

So we tell him to contact her doctor to tell him the trach size was changed. He proceedes to tell us that the doctor managing her is Dr. I. Are you kidding me??? Dr. I is a familly medicine doctor. He tried to manage my sisters high risk pregnancy, when he said that he never had a case like hers before. yeah right. Now he is managing a vented patient. Don’t you think a pulmonologist would be in order here? I’m just thinkin…

Things that would make my life easier

In case you wanted to know, I have been compiling lists in my head for
years. So let's start one now.

Things that would make (my) life easier.

1) when visiting family members in the hospital, do not loiter in the
hallway in front of the CT scanner. My vent dependant, levophed
dependent patient with bacterial menengitis, in DIC, with a bp of
70/40, mottled extremities and black, not just cyanotic, but black
hands (I'll try to get a picture) deserves the right of way. Don't all
come at once...You are in the way. Yes, I said it...You are in the way
of us taking care of your loved one. Now let us work without having to
worry about running over your feet.

Sorry if that sounds harsh, but its true. Can you tell I had an
incident at work today?

Now I feel better.

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6.67 20 108 2 -34

Needless to say, she didn't survive. A four day old beautiful baby girl. The most heart wrenching code I've been involved with in a long time. I did compressions for 45 minutes, my fingers hurt so bad, but I didn't want to stop.
Mom was begging us,

"please don't stop. Just a little bit longer, please."

It was horrible. Dad said,

"are you fucking kidding me?"

They just thought their baby wasn't feeding well.

In a blink...their lives are changed forever.

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