Good instincts

"You have good instincts." 

One of my coworkers told me that this morning.  It's probably one of the best compliments I could ask for as a nurse.  It says, "you're not just clinically competent, you're in tune with what's going in with your patients and you act on that knowledge judiciously."  Except it says that in four nice neat little words.

The woman I'd been caring for who inspired this comment was in her 60s, and in generally poor health.  She had emphysema and heart failure, diabetes and high blood pressure, the usually cocktail of chronic ailments that turn a local citizen into a "frequent flier" at our hospital.  This time she has gone into respiratory failure at her nursing facility, and was intubated and in our ICU for a few days before they stablized her, pulled out the breathing tube, and sent her up to our floor for further monitoring. 

At midnight when we met, she was alert and pleasant, on 4L of oxygen and breathing just fine.  She slept for a few hours, periodically ringing her call bell for assistance to the commode (a consequence of the diuretics she'd been taking as treatment for her heart failure).  At 0300, I went into the room to bring medication to her roommate, and found her sitting on the edge of the bed looking short of breath.  I listened to her lungs and heard some wheezing, checked her oxygen saturation and she was at 96%, which was more than adequate for a woman with her health problems.  However, the wheezes were concerning, and  I called the respiratory therapist to give her a breathing treatment. 

After the treatment she stated she felt better, but her lung sounds did not improve.  As she sat there, I watched her became lethargic and "out of it" as she spoke to me.  Her speech was becoming slurred, and while she still followed commands when I asked her to squeeze my hands, she just wasn't with it like she had been a few minutes before.  I checked her blood pressure and it was fine.  I checked her blood sugar, and it was high but not critically so.  The rest of her vitals, including her oxygen saturation, were still within normal limits, her heart monitor showed the same rhythm that she'd been in all along. 

But something was wrong.  She was not looking, sounding, or acting like the woman I'd met a few hours before.  This was more than just the three o'clock sleepies, or an asthma exacerbation.

I asked the nurse's aide to stay with the patient as I hurried out to the front desk, and when a coworker asked what was wrong, I said "one of my patients is going weird on me," as I dialed the beeper number for the physician.  When the doc didn't answer the page right away, I called the ER looking for her.  She came to the phone and irritably said, "when I don't answer a page that means I'm with a patient".  I ignored her tone and went on to tell her that my patient was having a sudden change in mental status and becoming lethargic with slurred speech.  I told her the results of my other assessments, which were all normal, and she irritably said "her vitals are stable, I'll be there when I can get there".  I thanked her and said that I hoped she would hurry, cause the woman seemed really off to me. 

This whole process took maybe four minutes. 

I entered the room again, and found the patient to be entirely unresponsive, blue, and barely breathing.  I called for a rapid response, ran for the crash cart, and started manually ventilating her.  Soon after, the physician and respiratory therapist arrived.  As I squeezed the bag forcing air into the woman's lungs, I watched her oxygen saturation rise from 45% (BAD!!!) back into the 90% range (good!).  No longer blue, but still not breathing on her own, we worked hard to stabilize her and get her to the ICU, a place she probably should not have left in the first place.

I recounted her medical history, the events of her hospitalization thus far, and what had happened during this episode to the physician.  I started a second IV site on her and gave her a sedative to help the anesthetist intubate her so she could be hooked back up to ventilator.  We did an EKG, a chest x-ray, blood work, and arterial blood gases.  We transported her to the intensive care unit, where she was put on a ventilator and prepared for further testing, and as I gave report to the nurse taking over her care, the woman woke up and scribbled on a notepad, "why do I have this tube in me again?!".  She was back.  She was alive, she was alert, she was going to make it.  I nearly laughed with relief.  So close to death, and she had no clue what had happened to her.

The snarky doctor who was so irritated that I'd interrupted her work for a "patient going weird" caught me in the hallway, thanked me for my help and said I'd done a great job.  I took it as an apology, and silently accepted. 

Each time a patient has gone south on me so far in my career, I've known it before it happened.  Even when the numbers and tests are telling me that they are at baseline, I've known that something was seriously wrong.  I'm not saying I'm psychic, don't get me wrong.  I've just had that nagging feeling that sometime wasn't right.  Each time I could have easily made the mistake of ignoring my instincts, of choosing not to speak up for fear of being wrong and looking dumb.  But each time I've made the choice to trust my gut, to look a little deeper, to make the phone call and say, "something isn't right here, and I think we have a problem.  Here is why."  It certainly isn't a vast amount of clinical experience (though each day of school and experience on the job is certainly helping!) that is guiding me to these decisions... I haven't been at this nursing gig for long.  But I do have pretty keen intuition, and each time I have put my trust in it a life has been saved as a result. 

Sometimes it pays big to trust yourself.
Trust yourself today. 
If the weather says a low of 43 degrees, but you feel a frost coming in your bones, cover the garden. 
If something in your gut tells you to take the scenic route instead of the freeway, allow for a few extra minutes of travel time and cruise. 
You never know when your instincts could be spot on, so play it safe, and remember the initials of nurses everywhere: C.Y.A.  Cover Your Ass.