Wednesday, May 28, 2008

Fun night

I wasn't with my usual night preceptor one night, though I don't think the events of the night would have gone differently if I was. Night.

One of my patients had gotten out of surgery earlier that evening and was to remain intubated and on the ventilator all night. Usually we try to wean patients off the ventilator and get the tube out as soon as the anesthesia has worn off sufficiently. Though I don't remember the one time I was on one, it's clear that people mostly do not care for ventilators. Instead of gently sucking in air as usual, patients now have a tube down their throat that blows air into their lungs. Unnatural, uncomfortable, and often anxiety-producing.

This young man was prescribed medication to decrease his anxiety and surgical pain. They weren't really keeping up despite a couple calls to doctors for increased dose and over the course of the night he was getting increasingly agitated. His hands were tied down with soft wrist restraints as we usually do with intubated patients who are not yet calm and rational enough to not grab for their tubes and IV lines. This guy was clearly not with it mentally, yet had the presence of mind to try wiggling down in bed so he could get hold of something to pull on. Several times an hour I had to readjust his position because he was close to grabbing his Foley catheter or airway suction line. Through rubbing it against the mattress, he managed to slightly dislodge the line going into his radial artery (the wrist) that measures blood pressure continuously. While I was trying to re-tape it, he yanked back and it came out. Great. I bandaged the site and got an order to follow cuff blood pressures instead.

With all this, and upon the advice of my temporary preceptor, I called a doctor to get the patient started on a sedation protocol where we could adjust a continuous drip of medication to the desired effect, calm and not fighting the restraints. Unfortunately, the middle of the night is not the best time to request the needed medication pumps as the supply staff is only a skeleton and take forever to deliver items.

At one point, I had to reach across this guy and hold his arm down because he was grasping at his chest tubes. These are tubes that are inserted between ribs or under the sternum to drain blood and other fluid from the chest after surgery. They also help reinflate lungs that have been deflated either for surgery or because of a pneumothorax (good picture of deflated lung and chest tube there). I couldn't go around the other side of the bed to readjust and retie his restraint because I was worried that during transit, he'd grab and pull his tubes out. I said, "Sir, I cannot let you pull your chest tubes out." He looked right at me and vigorously nodded as if to say, "Oh we'll see about that!" The other nurse in my pod had gone to the supply room and my preceptor had stepped away for a moment. So there I was leaned over the patient, holding his wrist, craning my head around toward the hallway waiting for someone to walk by. It was kinda funny. Kinda. After only a couple minutes, another nurse walked by and quickly came over to help.

Around 4:30 I started to give him his bath. My temp preceptor, who is a large, strong guy, held the restraints while I washed down the patient. Despite doses of medication before the bath, the patient was still agitated. The medication pump had arrived, but we hadn't titrated the medication up enough yet to have the desired effect. At one point while we were concentrating on his upper body, he managed to get his Foley catheter tubing between his toes and yanked on it. Um, dude. There is a balloon inflated in your bladder to anchor that catheter. You do NOT want to be yanking on that. Can you say traumatized urethra? Well, not with that tube down your throat.

Toward the end of the bath he settled down though. I was just finishing up redressing his surgical incision when the patient jerked suddenly and I looked up to see a look of shock on my preceptor's face. The patient, moving quickly, had grabbed a chest tube and yanked it out. My preceptor covered the hole with his glove and called for help, I ran to the supply room for some gauze impregnated with vaseline which is used to cover the hole so air doesn't leak in.

A couple other nurses came over to help and I paged the resident on-call to come reinsert the tube or suture the hole closed. Woken up in the sleep room, the resident was groggy when he called back and at first didn't really get what I was saying. "Just come down here now please," I said as nicely but firmly as I could. The patient wasn't putting out much fluid through the tube and had another one on the same side so when the resident showed up fully awake, he just sutured it closed. While he was working, early morning visiting time had come and I tried to head off the family before they came on the unit. I caught the mom in the hallway and explained the situation, worried she was going to panic. Nope. "I thought something like this might happen," she said looking apologetic, "He's a pretty anxious person usually. I sorry he's giving you so much trouble." Oookay, then.

From there, we switched to a different, more powerful sedation med which worked well. The pulmonary doctor showed up soon after, thinking she was going to be extubating him. "What's going on here?" she asked innocently. I told her the whole story and she sympathized. I paused the sedation med so she could see his behavior (it gets out of the system quickly) and within five minutes he was back to pulling and wiggling. By this time we were at shift change so I reported off to the next shift nurse and went home to well-deserved sleep.

A couple days later I walked by the same pod and saw the pulmonary doc. She beckoned me over saying, "Look here." I rounded the curtain and there was my guy, sitting in a chair eating dinner. Thanks to the amnesiac qualities of the sedation meds, he didn't remember a thing.


  1. oh boy, i never realized what being under might actually mean. i mean, sure, it makes sense you move around and react. if i ever have to go in for surgery, can i call up and get you to be my murse? i'd feel better knowing you're there:-)

  2. Most of the nurses in my unit are of the opinion that they'd be difficult when intubated. I think I could chill, but hard to know.
    And I wish I could be like a personal trainer and just go where my clients need me, but sadly that isn't the case. Plus, you probably don't want me to be the one giving you a bed bath and doing perineal care.

  3. okay, maybe not the bed bathing thing, or the weird i-have-to-check-out-your-booty time, but i would like you to be the one making sure i don't rip my tubes out:-) so i'll just come to you if i need that, okay?