Lives in the Balance: Nurses' Stories from the ICU

by Tilda Shalof

  This was Mick’s reality. To me, it seemed worse than death. My colleagues wholeheartedly agreed. Despite our personal feelings, though, we diligently kept up his care. It was so hard to see a proud man like Mick waste away like this. In fact, even as he lay comatose in the bed, trached and tube-fed, he held his head high in a very dignified manner.

  I wondered what his life might have been like had he simply accepted the advice of those first three cardiac surgeons whom he had consulted about having bypass surgery. I often wondered why Mick was so adamant about having this surgery. Whatever motivated him, it must have been powerful. His life must have been so difficult that he was willing to risk ending up like this—that is, if he even knew this existence could be one of the possible outcomes. I wasn’t sure he did. I’m not sure most laypeople really do. That is why advance directives are so very important. Medical science may be able to keep you alive but the real question is, what does being alive mean to you?

  I wasn’t present when Mick consulted the cardiac surgeon. I wondered if the surgeon, in his zeal to operate, told Mick about the risk of ending up like this, if he informed Mick in any real, substantive way. But there was no way for me to know the answers to these questions. Mick could not tell me and I had never met a family member—until now.

  I took the opportunity to ask Mick’s wife why he pushed so hard to have the surgery even though three other doctors had refused him. Her response was a jaw-dropper.

  “We knew Mickey had heart problems; the doctors told us. But it never gave him any trouble. It’s just that he couldn’t play a full round of tennis without getting short of breath and having to sit down. It really bothered him. He kept saying he just wanted to be able to play a good game of tennis like he used to.”

  For some reason, whenever the phrase “Tennis, anyone?” comes to mind, I still think of Mick.

  About two months later, Mick died from a cardiac arrest. His had been a wrenching ten-month battle in a state somewhere between life and death—a living limbo created by advanced medical technology. I suppose it could be argued that this particular patient’s condition had improved: the battle was over and the suffering ended. Maybe Mick’s spirit is somewhere in the afterlife, playing that good game of tennis.

  Not Just the Patient

  Gina Rybolt, RN, BScN

  I WAS AT THE DESK looking over an EKG when a patient’s wife came running out to the nursing station.

  “Please come quick! Someone come check on my husband!”

  These can be scary words for a nurse to hear. What does it take for a concerned family member to come running for help? At times the reason is fairly benign: the patient has started coughing or says he is having pain. Other times it’s that the patient, connected to all kinds of tubes and wires, is confused and trying to get out of bed. Or they’re pulling on those very important tubes and wires. You never know until you get to the patient and assess the situation for yourself.

  I hadn’t heard any alarms; I checked the monitor and saw nothing unusual. But with ten years of ICU experience, I knew well the fundamental nursing adage that we “treat the patient, not the machines.” However, the monitor was in my immediate vicinity; the patient was not. These large, lit-up screens, full of numbers, waveforms, and flashing lights, give us a snapshot of every patient’s vital signs and condition. If the parameters we’ve set are reached, an alarm sounds. Experienced ICU nurses are able to discern which alarms are urgent and which ones aren’t. Some alarms indicate an emergency; some just let us know that the oxygen probe fell off the patient’s finger. A glance told me that this patient’s current vital signs (pulse, blood pressure, oxygen level) were normal. However, even normal vital signs on a monitor can be misleading. So I headed into his room, right behind his wife.

  “He’s breathing fast, he’s coughing, and his pulse is really high!”

  I looked at the patient. In his mid-sixties, he was suffering from a bad pneumonia. His recovery had been rocky and he would require a ventilator to help him breathe until the infection was taken care of. Despite the ventilator’s support he did look as though he was breathing too fast. The numbers on the vent confirmed this, showing that he was breathing over 40 times per minute. Looking at the monitor, I saw that his oxygen level was fine and that his heart rate was well within normal limits, at 88. So although his breathing rate was fast, his other vital signs were encouragingly stable. I turned toward the wife; she knew what I was going to say.

  “Well, it was 102 a second ago!!”

  “But it’s okay now. And you’re right, he is breathing fast. This is the second day that we’ve tried to wean him from the ventilator and he’s not fully tolerating the lower settings. I believe he tolerated it well at first and now he’s getting tired. His nurse is in with her other patient; I’ll go let her know. We’ll put him back on the higher settings and let him rest.”

  Her shoulders relaxed almost imperceptibly but then tensed up again as she looked back at her husband lying in the bed. She started wringing her hands and talking defensively. “I don’t usually panic like this, it really does take a lot to …”

  I put my hand on her shoulder as I interrupted her.

  “But he’s your husband.” I don’t know what she was expecting me to say, but it wasn’t that. Her face showed a split second of surprise before her shoulders relaxed entirely. Every feature of her face showed utter and complete relief.

  “Yes,” she nodded. “He’s my husband. Thank you for saying that.”

  As nurses, our focus is the patient. But we take care of the families, too.

  Making Mischief in the Night

  Janet Hale, RN

  I’VE BEEN A critical care nurse for 28 years and still find the ICU as fascinating as ever. However, for some time, I’d been searching for a new challenge. About a year ago I found what I was looking for—and my career got a huge jolt of energy and renewal at the same time: I made the decision to join my hospital’s Critical Care Rapid Response Team. I knew my learning curve would be steep and my responsibilities great.

  The Rapid Response Team is a relatively recent initiative in many medical centers. It’s designed to bring the knowledge, skill, and expertise of the ICU to patients on the floor. ICU nurses are the first responders to a patient in need, wherever in the hospital that patient is. In collaboration with the rest of the ICU team, we intervene quickly; in some cases we can fix a problem in a patient’s condition before it worsens. Often, we are able to avert an admission to the ICU. If we are summoned early enough, we are able to abort a cascade of worsening events and improve a patient’s outcome. Sometimes, however, a patient is too unstable to be managed on the floor and does end up being brought to the ICU. Whatever the situation, if a nurse, doctor, or family member on the floor picks up on a sign that something is not quite right with the patient, we are available around the clock to respond immediately. The warning sign might be as subtle as a hunch or a vague impression or as obvious as an irregular heartbeat, drop in blood pressure, or change in level of consciousness, any of which could signal an impending cardiac or respiratory arrest.

  One thing’s for sure: when my beeper goes off, I know there’s a patient on the floor who’s getting into mischief!

  I want to tell you about a recent shift I had on the Rapid Response Team.

  I was called at about 3:30 A.M. about a patient whose condition was deteriorating. Mrs. Maunders was a 46-year-old woman who had end-stage liver disease as a result of a rare condition called Wilson’s disease. She had been unstable for a few hours and the nursing staff was very concerned about her. It turned out they were right. When I arrived, I took one look at the patient and knew it was serious. Mrs. Maunders was sitting bolt upright in bed. Her “work of breathing” was extremely labored; her oxygen saturations were falling into the mid-70s: she was in impending respiratory arrest. I pulled my outreach cart, which is equipped with monitors, medications, and other ICU equipment, into the room and parked it beside her bed. I rolled a computer clos
er to take a look at her chest x-ray; there on the screen I immediately saw the likely source of Mrs. Maunders’s breathing problems. She had a large pocket of fluid, likely a pleural effusion, on her right lung.

  Her oxygen flow was already up to 100 percent by face mask, so delivering more oxygen to her was impossible. I knew we’d probably have to intubate her to improve her respiratory condition.

  As I made these assessments, I noted another worrisome sign: her skin color was a greenish orange. I knew the color was a sign that bilirubin was building up in her system, due to her liver failure, which was worsening fast. That reminded me to check her coagulation status, which, sure enough was disrupted due to her liver dysfunction. We would have to correct her INR, or bleeding time, before we drained that fluid collection on her lung. If we tried to drain the fluid before we normalized her bleeding time, she might hemorrhage. I therefore ordered four units of fresh frozen plasma, which contains factors that decrease bleeding time, from the blood bank. Hopefully, once the fluid was safely removed, her breathing would ease and she would no longer be dependent on the ventilator. Ultimately, if we could get her through this life-threatening event, we could stabilize her and then, hopefully, a suitable liver would become available and she could get the transplant that could save her life.

  Should we send her to the step-down unit? the ICU resident asked me. There, she would be more closely monitored than she could be on the floor. Normally, this would be acceptable, but it was a short-term solution only. Luckily, I had checked out the bed and staffing situation in the ICU at the beginning of my shift, as I always do. I knew there was a patient there who had had a lung transplant a few days ago who was doing very well. It had been on a Friday the 13th, but he had told me it was the luckiest day of the year for him! He was doing remarkably well, was on “room air” with no supplemental oxygen, and was waiting for a bed in the step-down to become available. It is never pleasant to wake someone up and transfer them out to a floor in the middle of the night, but I knew that that patient was “flying right.” He was stable and no longer needed the ICU—and here was a patient, desperately ill, who, in my humble opinion (those who know me know I am far from humble when expressing my opinion on such matters), did need a bed in the ICU. Yet, that patient’s transfer to step-down was stalled. Nothing was happening.

  It was up to me to make things happen—and fast—because Mrs. Maunders was about to arrest. She needed to be in the ICU. Let’s not waste any more precious time! Let’s bring this sick patient to the ICU where she can get the treatment she needs, I thought to myself. I called Mary Lou King, our nursing supervisor, who is always respectful of nurses’ judgment, and asked her to get the transportation people and housekeeping to come quickly, to move and clean beds, so that I could get this mission underway, pronto!

  I looked at our ICU resident. She was exhausted, having been up all that day attending to all the other of our 24 ICU patients. But she realized that we had no choice but to play musical beds in the middle of the night in order to get Mrs. Maunders into the ICU. She agreed with my assessment of the patient’s condition and my decision to transfer out the other patient in order to bring Mrs. Maunders to the ICU.

  When Mrs. Maunders heard she was going to be transferred to the ICU, she was relieved, but then she panicked. “Does this mean I’m dying?” she managed to say, between gasping breaths. No, I assured her, we were doing everything we could to help her.

  “Is this it, am I going to die?” she repeated.

  To myself, I had to admit that she might just be right. But I knew I was going to do everything I could so that wouldn’t happen. What Mrs. Maunders needed at that moment was hope and something to hold on to—which, come to think of it, are probably the same thing.

  “No,” I said, “we’re going to help you.” What this patient really needed was a liver transplant, but I had no idea whether that would happen for her. “We are going to support you,” I told her. “We’re bringing you to the ICU so that we can help you more than we can here. We want to make sure you don’t get into any more trouble.” When I teased her like that, as I sometimes do with patients, her face brightened. She understood that the ICU was a sign of hope for her. I felt proud of what we could offer her in the ICU. “You’re in good hands,” I told her. “Our team is going to try our best to help you.” She still looked worried, but took me on my word.

  Now, the immediate concern was intubating her and ventilating her until we could drain the fluid in her lungs. We had to sedate her, too, so that she would be able to tolerate the intubation and ventilation—not pleasant experiences by any stretch of the imagination. While all this was happening, my beeper went off yet again; I had to move on to see another patient. I left Mrs. Maunders in the ICU, handing her over to my very capable ICU colleagues. I had no idea what the outcome would be for her but I felt satisfied that we had done everything we could to help her.

  When I came in the next evening I made a “drive-by” to Mrs. Maunders’ room and saw that she was resting comfortably, her daughter at her side, visiting. The ICU team had done everything I had hoped for. Mrs. Maunders was still intubated, but she was awake enough to recognize me immediately. She was so thankful and wanted to tell me how she felt. She couldn’t speak because of the tube in her mouth, so she wrote a note on a scrap of paper, to tell me how thankful she was for me having saved her life.

  It’s hard for me to take credit for what I did. I am a part of a team and a lot of other professionals also had had a hand in her recovery, but it felt wonderful to be recognized. I knew I had done a good job and had made a huge difference in one woman’s life.

  I reassured Mrs. Maunders that once she left the ICU, the Critical Care Response Team would follow her through her transfer to the step-down unit, and then back onto the floor. And then, hopefully, she would go home.

  An Uneasy Feeling

  Kathy Haley, RN

  I’VE BEEN AN ICU nurse for 21 years. For the past four years, in addition to my role as a staff nurse in a medical-surgical ICU, I have also been a member of our Critical Care Rapid Response Team. I enjoy working with this group of professionals that goes out to patients in trouble on the floors. When I’m working as the nurse on the CCRT, I am usually the first one called to assess the situation. We use our critical care skills, which we learned in the ICU, and take them out to other areas of the hospital. The “Outreach” program, as it’s also called, has proven to be beneficial: we have been able to help patients on the floors and either prevent them from needing to come to the ICU or get them to the ICU sooner and treat them before things get much worse.

  I remember a patient who I went to see on the medical floor. She was an elderly woman who had been admitted for an exacerbation of a long-standing respiratory illness: chronic obstructive pulmonary disease, or COPD. The Outreach team had been asked to see her for her ongoing problem of shortness of breath. We had already been following her for a couple of days when I went to see her one Friday morning. It was recorded in her chart that she was improving. She was now able to speak a full sentence without getting short of breath. The plan was to discharge her home on Monday, after the weekend. I asked her how she was feeling. She told me that she had just come from the bathroom. I could see she was short of breath from the exertion that that short trip, just a few steps from her bed, had cost her. I continued my physical assessment of her and watched her closely. I reported my findings to her nurse and to my staff physician, who was in charge of the CCRT that day.

  But there was something beyond my immediate findings that was difficult to express. I had a strong feeling that something was wrong. It wasn’t based on hard evidence, because her vital signs were stable and I’d found nothing amiss in her laboratory results or in my physical examination of her. Nevertheless, I felt uneasy about the plan to discharge this patient. I kept having a nagging feeling that something was wrong, that we were missing something. I’ve learned to trust those gut instincts. I decided to keep this patient on my list of f
ollow-up patients to see over the weekend. I met with the patient’s daughter and explained why I was continuing to see her mother. I promised I would follow up with her mother again the next day—but later that same day, I returned with the ICU medical resident to see this patient again.

  The patient still seemed stable. She had no particular complaints. She was eager to go home and the plan to discharge her home on Monday was still in place. And still, despite all of this, my uneasy feeling persisted. The next day, a Saturday morning, I went straight back to the floor. The moment I entered the patient’s room, I could see she was seriously short of breath. Her color was not good. She winced in pain when I palpated her belly and at one point even doubled over with abdominal pain. The patient’s family arrived and we explained that we suspected something serious was happening. We would be taking their mother to the ICU right away.

  As soon as we transferred her to the ICU, she was intubated and then taken for a CT scan of her abdomen. The scan revealed that she had a small leak into her abdominal cavity caused by a perforation of her intestine. The patient was soon taken to the operating room; a few weeks later she recovered and went home.

  About a year later, around Christmastime, the patient and her daughter came into the ICU to say hello. I happened to be working that day. The patient did not remember her stay in the ICU or any of the people who had cared for her. But her daughter did. She introduced me to her mother as “the person who saved your life.” She explained to her mother how I had had a feeling that something was not right and how I had kept coming back to check on her. I felt both proud and humbled by what the daughter had said. It was absolutely true and I felt very fortunate for having my wealth of ICU experience and my ICU skills. I was grateful that I’d stayed alert to my feeling of unease, even when I didn’t have hard evidence to back it up.