today i found myself in the middle of a code.
i had admitted this patient several weeks ago. he was in his 60s. he had a cardiac history, not unlike my father's. and his wife was kind. they walked the halls together hand in hand. and sure enough, not surprisingly, part way into his chemotherapy, his heart started to act up. i hadn't seen much of him since he was transferred to our intensive care. i don't tend to spend much time back there - on purpose! but compared to other ICU patients, this patient was doing decently. he was not yet intubated. his lungs had not failed him yet. infection wasn't yet riddling his body. it was just his heart. it continued to beat erratically and uncontrolled, despite medication. and this morning, his blood pressure dropped to dangerous levels. i can't really discuss the complexities of his care because i was uninvolved.
but at 10:26, when a code blue was called on my unit, i found myself in the midst. i was planning to go back to the room, check to see if things were under control. sometimes nurses need more supplies. sometimes i can run and get the code cart. most of the time though, i hang out in the halls with the family - with distraught loved ones. i get chairs and boxes of kleenex. i explain that the nurses and doctors are doing all that they can do and once things are more stable, someone will come out to give them an update. i ask if i can make calls, to relatives, friends, whomever. but typically, i stay OUT OF THE ROOM.
today was different. i've been on my unit for more than 5 years. i'm more than capable of helping out. and so, when the charge nurse asked if i would come in and record, i did. the recorder actually has a significant role. as vital signs are taken, i document them. as shocks are given, i write the time and the number of joules. when pharmacy delivers medications, i note the amounts and the times given. at different intervals throughout the code, all eyes are on me to list the names, amounts, and times certain medications were administered. epinephrine. calcium gluconate. atropine. sodium bicarbonate. lidocaine. paralytics. vasopressin.
people did chest compressions for two minute intervals. an airway was introduced and the respiratory therapists breathed for the patient. doctors discussed likely causes for sudden death. ALL CLEAR was yelled before the paddles delivered the unsuccessful shock. several rounds of epinephrine were given, in an attempt to restart the heart. but all of it was futile. at 10:47, the pulmonary fellow pronounced it. "time of death 10:47." just like on TV. within seconds, the room cleared. the 20 people who gathered to assist took off their rubber gloves and gowns and dispersed within the hospital. in less than 1 minute, i was left in the room with just the patient's nurse, the charge nurse, and a deceased man.
i often think my job is strange. i find myself in strange situations. but today, i couldn't help but feel extra weird. for 21 minutes, i witnessed medicine in action. for 21 minutes, heroic measures were attempted to bring a dead patient back to life. for 21 minutes, dozens of people worked harmoniously on the same "project," for the same purpose. and after 21 minutes of hard work and intense efforts, a human being died. it's so strange that in just 21 minutes so many things can change. our unit had one less patient. one nurse no longer had a person to care for. and one wife no longer has a husband.
Monday, January 23, 2012
Saturday, January 21, 2012
DNR
"CODE STATUS: the patient is a full code (clarified on 1/20/2012). she would like CPR and intubation but does not want to be on a ventilator."
this is a direct quote written in a legal medical document by the resident i fought with yesterday at work. for those non-medical folks out there, perhaps this sounds fine. there's some medical jargon, something about life-sustaining treatment, sounds like maybe the doctor wants to respect a patient's wishes. but for the medical people, this comment should sound assinine! who gets intubated (tube down throat to support one's airway and lungs) without requiring ventilation (the machine used to breathe for a person).
more frustrating than this stupid comment is that this was NOT what my patient wanted. being the kind, inquisitive nurse that i am, prior to sedating this patient for a procedure, i wanted to understand my patient's wishes should an emergency take place under my watch. after a very thorough conversation, it was made clear to me that the patient NEVER wanted to be kept alive by machines. she acknowledged that she's 62, that she's already had 3 kinds of cancer, that she would likely not survive the stem cell transplant her team of physicians is recommending, and that everyone must die somehow. while the patient wasn't ready to die during the conscious sedation i was about to provide (where i run the risk of oversedating her and needing to code her), she does not want medically futile treatment.
SO, i called the resident. i told him there was a discrepancy in what he thought the patient wanted and what i KNEW the patient wanted. he was stupid. he asked me what time i talked to the patient. all fucking day idiot - that's the difference between nurses and physicians. i didn't say that. instead i said "noon." he said, like an 8 year old, "well i talked to her at one." i doubted that in those 60 minutes the patient changed her mind. when we discussed her wishes as stated in his medical note, i explained that CPR and intubation without ventilation made zero sense. he couldn't seem to support his comment or his thinking, so i demanded to speak with his attending. i had nurses around me at the nurses station listening in awe; i am typically kind and respectful, but not regarding life and death issues. i was being defiant. an advocate for my patient. i was NOT about to do CPR on a patient that clearly did not want CPR, simply because the physician i was working with was an idiot.
instead of getting his attending involved and because the palliative care team who does the death talk better than ALL doctors was busy, the resident agreed to meet with me and the patient. he actually called me and asked me to be present - thank god. so we had the talk with the patient, each of us for the second time in the same day. and within minutes, it was very clear that the patient DID NOT want CPR. she did not want to have her ribs broken, her lungs perforated. when she heard the survival rates from a code situation she said, "why are we talking about this? i do not want that." i wanted to stick my tongue out at the doctor. what kind of conversation must he have had with the patient only hours previously that made him think she wanted extreme heroic measures? how come doctors suck at communicating with patients about dying? and why as a nurse do i feel relatively comfortable broaching the subject and extremely passionate about people who are brave enough to die naturally, when nature takes its course?
at the end of the day, i felt good. i had placed a DNR bracelet on my patient (to alert staff that she does not want to be resuscitated). and i had put a doctor in his place - shown him that my communication skills are superior to his, that he should listen to nurses, and include them in conversations with their patients. but mostly i felt good because i understood and respected my patient's wishes. when i said goodnight to my patient last night she said, "thank you for being excellent."
this is a direct quote written in a legal medical document by the resident i fought with yesterday at work. for those non-medical folks out there, perhaps this sounds fine. there's some medical jargon, something about life-sustaining treatment, sounds like maybe the doctor wants to respect a patient's wishes. but for the medical people, this comment should sound assinine! who gets intubated (tube down throat to support one's airway and lungs) without requiring ventilation (the machine used to breathe for a person).
more frustrating than this stupid comment is that this was NOT what my patient wanted. being the kind, inquisitive nurse that i am, prior to sedating this patient for a procedure, i wanted to understand my patient's wishes should an emergency take place under my watch. after a very thorough conversation, it was made clear to me that the patient NEVER wanted to be kept alive by machines. she acknowledged that she's 62, that she's already had 3 kinds of cancer, that she would likely not survive the stem cell transplant her team of physicians is recommending, and that everyone must die somehow. while the patient wasn't ready to die during the conscious sedation i was about to provide (where i run the risk of oversedating her and needing to code her), she does not want medically futile treatment.
SO, i called the resident. i told him there was a discrepancy in what he thought the patient wanted and what i KNEW the patient wanted. he was stupid. he asked me what time i talked to the patient. all fucking day idiot - that's the difference between nurses and physicians. i didn't say that. instead i said "noon." he said, like an 8 year old, "well i talked to her at one." i doubted that in those 60 minutes the patient changed her mind. when we discussed her wishes as stated in his medical note, i explained that CPR and intubation without ventilation made zero sense. he couldn't seem to support his comment or his thinking, so i demanded to speak with his attending. i had nurses around me at the nurses station listening in awe; i am typically kind and respectful, but not regarding life and death issues. i was being defiant. an advocate for my patient. i was NOT about to do CPR on a patient that clearly did not want CPR, simply because the physician i was working with was an idiot.
instead of getting his attending involved and because the palliative care team who does the death talk better than ALL doctors was busy, the resident agreed to meet with me and the patient. he actually called me and asked me to be present - thank god. so we had the talk with the patient, each of us for the second time in the same day. and within minutes, it was very clear that the patient DID NOT want CPR. she did not want to have her ribs broken, her lungs perforated. when she heard the survival rates from a code situation she said, "why are we talking about this? i do not want that." i wanted to stick my tongue out at the doctor. what kind of conversation must he have had with the patient only hours previously that made him think she wanted extreme heroic measures? how come doctors suck at communicating with patients about dying? and why as a nurse do i feel relatively comfortable broaching the subject and extremely passionate about people who are brave enough to die naturally, when nature takes its course?
at the end of the day, i felt good. i had placed a DNR bracelet on my patient (to alert staff that she does not want to be resuscitated). and i had put a doctor in his place - shown him that my communication skills are superior to his, that he should listen to nurses, and include them in conversations with their patients. but mostly i felt good because i understood and respected my patient's wishes. when i said goodnight to my patient last night she said, "thank you for being excellent."
Wednesday, January 18, 2012
snow day
i just worked the last three days. snow fleeted outside my patients' windows blanketing the world below in white fluff. from our 8th floor windows it looked peaceful and quiet - a winter wonderland! but in my head, i couldn't help but stress about how to get to and from work should the streets be icy (my 17 year old camry is not the best in snow and neither is it's owner). nurses don't really get to call in "sick" from work because they can't make it in to the "office." hospitals don't shut down. and they don't run very well if and when a good majority of the staff can't show up.
thankfully i have the day off today. instead of walking three miles in to work at 6 AM (like the dedicated employee that i am), i got to sleep in until 8:30, nurse my on-the-verge-of-being-sick body, and putz around the house. i've done dishes, folded laundry, walked to trader joe's, and am currently sitting in the warmth of elliot bay bookstore sipping on a sweet latte with plans of reading a good book.
ahh, here's to a rare seattle snow day! i feel like a kid again, hoping school will be cancelled and lots of hot chocolate will be gulped!
thankfully i have the day off today. instead of walking three miles in to work at 6 AM (like the dedicated employee that i am), i got to sleep in until 8:30, nurse my on-the-verge-of-being-sick body, and putz around the house. i've done dishes, folded laundry, walked to trader joe's, and am currently sitting in the warmth of elliot bay bookstore sipping on a sweet latte with plans of reading a good book.
ahh, here's to a rare seattle snow day! i feel like a kid again, hoping school will be cancelled and lots of hot chocolate will be gulped!
Wednesday, January 11, 2012
caffeine on christmas
i had every good intention of writing a new year's post, full of optimism and hope for a fantastic 2012. and somehow, i've let the beginning of the month get away from me. instead of acknowledging that it's almost mid-january, i'm going to take a little look back and share part of my family's holiday tradition. as a nurse, i work every other christmas. it can be a bit of a drag. i remember my first year as a nurse, i was SO bummed. i cried when i told my mom that i would be missing the family christmas celebration (she cried too). and every other year since, i have put on my scrubs at 6 AM and my mom and aunt joanie drive me to work, not before finding the only starbucks open before 7AM to get myself the much needed caffeine boost to start my day.
on years that i do not work, i celebrate with my family... and because i know it's hard to work on christmas, i ALSO choose to celebrate with my colleagues. between 3PM and 5PM, work is always the hardest. typically, the busiest part of our day is over and we're watching the clock, waiting for 7:30PM to come - and it never comes soon enough. so, my mom's, joanie's, and my new christmas tradition involves a caffeine delivery (around 3PM) to the hospital with personalized orders and festive starbucks cups! joanie loves to tell my work friends about santa's generosity and her upcoming plans (this year it's a trip to vegas baby!). my mom and i enjoy a christmas cookie or two from the potluck leftovers and chat with nurses. and at the end of the day, everyone is happier thanks to caffeine on christmas!!!
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