I was caring for a sickly man in his 50s with multiple health issues, two of which were low blood sugar levels in the mornings, and chronic pain in his legs. His pain had been poorly controlled on the oral Dilaudid the whole previous day, despite taking it every four hours... so the doctor changed the order to IV Dilaudid. Shortly after midnight, I entered his room to assess him, and found him stable, but in pain. I brought him his scheduled dose of Dilaudid, and a little bedtime snack to try to keep his blood sugar from crashing out at 6am as it had been doing for the past several days. I checked on him half an hour later, and found him resting comfortably, stating that his pain was relieved and that he thought he could actually get some sleep. I wished him a good night's rest and continued with the business of my night.
Throughout the night, though it was a very busy one with 6 patients and NO nurse's aides on the floor, I checked on all of my patients at least once each hour. Each time I checked on this gentleman, he was either awake and watching TV or sleeping comfortably, with a gentle snore. His color looked good, his breathing unlabored, all was well. At 5:30am, I entered his room to check his blood sugar. He did not wake up when I pricked his finger for the blood sample, but this did not cause me alarm, as patients will often sleep through this testing, especially if they have neuropathy of their extremities, as this man did. He was still snoring quietly, breathing easily, and his fingertips were pink. His blood sugar was well within the normal range, and I was relieved. I moved on to the next task.
40 minutes later, I was walking past his room on my way to see another patient... and I just had a feeling. I entered the room, and found this man slumped over in bed, cyanotic, soaked in sweat, and breathing in a very labored way. I shook him, hard, calling out his name... no response. I rubbed my knuckles into his sternum with painful force... nothing. I pulled his pillow out from underneath his head so I could assess his pulse, and he flopped onto the bed, limp, mouth lolling open. Horrible. I ran out into the hallway, telling one of my fellow nurses that I couldn't get my guy to wake up, and grabbed the pulse oximeter and blood glucose machine, running at full speed back into the room. I was sure this guy's blood sugar had somehow bottomed out on me.
I check his blood oxygen level with the pulseox... he's at 47% on room air. You should be at least above 92%. I ask one of the nurses to call the Rapid Response team, and grab me some 02 tubing and a mask. I check his blood sugar. It's perfectly fine. "But that doesn't make sense," I think. One of the other nurses had even said "oh yeah his sugar is definitely low, look at the sweat on him" and had run into the med room to get some IV Dextrose. He LOOKS like textbook hypoglycemia. I check it again, on the other hand. Still fine. What the hell?? Could it be the narcotics? I gave that dose of Dilaudid nearly 6 hours ago, and he had no issues all night! How could his respiration be depressed from that NOW??
The rapid response team arrived, and we began pushing air into his lungs with the Ambu-bag. We attempted to find the guy from anesthesia, find that he need to be sedated in order to get a tube down his throat (he was clamping his jaw shut), but guess what, they leave at 0630! We sent someone out to call around to find the CRNA from the OR. The physician arrived shortly thereafter. I'm checking the man's pulse, which was still strong, and trying to get another good reading on the pulseox. Another nurse is trying to start a second IV, another is getting his blood pressure. The monitor tech calls in that he is still in normal sinus rhythm. "What's this guy's story?" the doctor asks me.
I freeze. My mouth goes dry. I can't even remember the man's name. "I am totally blanking out right now." I say aloud. I recite what had happened in the past fifteen minutes, and what had happened since the beginning of my shift. The physician starts grilling me on this guy's health history, social history, etc... details of his life that my adrenaline is not allowing me to remember, and my note sheet is nowhere to be found in this chaotic room.
Finally, after about 8 minutes of stuttering disorganized thoughts, my brain is starting to unfreeze and I'm recalling his history, labwork, and how much Dilaudid he had receieved orally the previous day. Now this makes sense... his liver function wasn't the greatest, and all that oral Dilaudid he'd received previously was probably building up in his system and just caught up with him during the witching hour that morning. The CRNA arrives and sedates him so the respiratory therapist can intubate him, and his oxygen level finally begins to rise. However, his blood pressure tanks from the sedative. We push a bag of fluid into him as fast we can, my hands aching as I literally squeeze the bag to force the saline in.
We rush him to the intensive care unit, where he's hooked up to a ventilator and started in a drug to keep his blood pressure up. He's still blue, and going rigid at this point, and his core temperature is low. I give report to the nurse taking over, finding myself now able to think clearly. She smiles at me, says she's got it from here. I scribble a note on the chart recounting the events of the morning, double check the rapid response team record for accuracy, and sigh as I head back upstairs to clean up the mess, reassure the man's roommate, and give report on the rest of my patients to the oncoming shift.
I leave late, sit down in my car, and burst into tears. Had I missed something? When did things go wrong? Could he have been in that state when I'd checked on him earlier in the morning, had I not noticed?? Why did my brain completely shut down on me in the middle of that? How much of an idiot do my coworkers think I am right now? Is that man going to die? Is it my fault?
I cried the whole way home. I had nightmares about it as I slept that afternoon. When I woke up that evening and got into the shower for work, I cried again, dreading going back into work for fear of finding out what happened. I stopped at the grocery store on the way in, grabbing some cookies to thank my coworkers for their help and support.
When I arrived, everyone who had been there the night before told me that I'd done a great job, that I knew my patient well and that it was normal not to be able to answer those kinds of questions in the middle of a crisis. My supervisor reassured me that I did exactly what should have been done, and that there was no way that man could have been in that state for very long before I found him. They also informed me that earlier that day, he'd pulled his own breathing tube out and walked out of the hospital against medical advice. We all knew he'd be back before too long, but it was a relief to know that he'd pulled through.
Even if they'd told me all of this the morning of the event, I know I still would have cried in my car on the way home. It was too horrible not to. The color of that man's skin, his body dropping limply onto the bed, his chest heaving maybe twice per minute...and then the coarse gurgling sound as the air was pushed through the tube into his lungs... it was terrible. To go from being awake, alert, and talking to THAT... it was traumatic.
I've had people go into distress, I've had people go into deadly arrhythmias, and I've had people die. But I've never had a patient have such a rapid and drastic change in status before... and it was terrifying. Some parts of my brain functioned... the ones that knew what emergent steps I needed to take to keep the guy from dying... the ones that knew how to hook up IV tubing, enter my user code in the blood glucose machine, and look for a femoral pulse. But other parts of my brain completely shut down as my body reacted to the situation with complete and utter panic.
The other nurses praised me for keeping my cool, so I suppose it must not have shown... but on the inside, I was a boiling vat of anxiety. I suppose that is normal in a crisis situation... but I have learned now to NEVER let my clipboard leave my side again. That sheet of paper with my notes written on it would have saved me from those 8 minutes of flustered bumbling, and might have held vital information that my crisis-activated-brain could not recall.
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