Tuesday, December 01, 2009

A patient with Down's Syndrome and ARDS; Carol was not "my" patient

Not My Patient . . .

“Your patient is being discharged,” my nursing instructor informed me as we started our clinical rotation on a medical/surgical floor in my first year of nursing school.

"Oh, just great," I thought to myself.  I had spent hours learning about and planning the proper care for "my patient" who had recently suffered a basilar skull fracture.  My sheaf of clinical documents, medication lists, and a large pathophysiology flow sheet, were now suddenly made obsolete by my patient's imminent departure to a rehabilitation facility.

“He’ll still be here for a couple of hours. We’ll find you another patient later,” she assured me.

I was relieved that my painstakingly-crafted flow sheet, care plan, and medication cards wouldn’t go to waste. Although I only had one patient, the preparation required for the clinical day was nevertheless tedious and often proved exhausting in addition to other demands of family, school, and life in general.  Still, as a new nursing student with little experience in the healthcare setting, the advance preparation gave me confidence that I would know what to do for my assigned patient.  I decided not to fret about it, and simply hoped I'd be able to cope with whatever came my way in the shift ahead.

Our group of 10 nursing students and our instructor assembled at the nursing desk waiting for the nurses going off duty to give change of shift report to the group coming on.  We were working second shift, 3 pm to 11 pm that day.  Each week we spent three days attending lectures at our nursing college and two days working in the hospital to practice the hands-on-nursing skills and put into practice what we learned in class.  There was always a sense of heightened anxiety on our hospital days, particularly in the chaotic environment of our very large county hospital. This was a trauma center and the busiest hospital on the U.S. side of the Mexican border. It was also a teaching hospital, with a slew of resident doctors and interns managing most of the patient care. 

“The patient in 410 has a fever of 101.5!” a nursing assistant called out as she passed the nurses’ station where the harried day-shift nurse was “reporting off” to the oncoming "real" evening nurse and our huddle of nursing students.

The nurse going off shift sighed, “I’ll call the doctor—the girl in 410 just transferred here from the pediatric floor a half-hour ago. She’s supposed to go to the OR for surgery, an ORIF of the femur, as soon as her mom gets here to sign the consent.” The RN turned to our instructor, “It would help me out if one of your students could give her an acetaminophen suppository for the fever.”

Although none of our group was assigned to care for this new arrival to the surgical floor, we were always ready to perform a clinical skill to check off our list.  Therefore, an entourage of three students and our instructor entered room 410 where 18-year-old Carol, afflicted with Down's Syndrome and a fractured femur, would prove to teach me more than any other patient that day.

Carol had been struck by a car as she crossed a busy street the day before.  The fractured leg was her only known injury. She appeared to be sleeping deeply, with regular, but deep and fast respirations. Her eyelids fluttered as I explained that we needed to give her a suppository. Working together, we students gently repositioned her, mindful of the Buck's traction supporting her injured leg. A slight groan was Carol’s only acknowledgement as we cleaned her bottom (she had been incontinent with a bowel movement), before I inserted the suppository. Our instructor pointed out scattered petechiae on Carol's chest as we snapped a fresh gown across her hot skin and turned her to replace the soiled linen on her bed with clean sheets.

“These petechiae are probably the result of the trauma from her car accident,” our instructor explained, as she gestured towards the splash of flat pink spots that looked to me like tiny red freckles.

Back at the nurses' station our little group reassembled to continue shift report.  We told the nurse about our interventions and reported Carol's limited response to our actions.

“They gave her an injection of Demerol before she was transferred from the pediatric unit," the nurse mused, "And we don’t know her baseline mental status, she has Down's, and for all we know she could be profoundly retarded.” 

I was absorbed in my clinical experience for a few hours. The care for my basilar skull fracture patient proved to be very minimal. One of our nursing students needed a helping hand with a very complicated dressing change for a young man who had lost a leg in while trying to jump aboard a moving train.  And I was pleased to learn that another patient needed a new intravenous needle placed.  I was lucky enough to get the chance to do the venipuncture.  I suspect that I caused that patient a great deal of pain with my novice attempt, but with a seasoned nurse over my shoulder talking me through it, the result was satisfactory.  I kept busy in this way helping the staff nurses and other nursing students with their tasks until my patient was officially discharged.  My instructor disappointed me then by suggesting that I return to Carol and follow up on her care. It seemed a puzzling assignment to me, I knew there were no meds to pass, IV's to start or dressings to change in that room--and I was here to learn nursing . . . 

In Carol’s room I found that her mother had arrived from out-of-state.  She was regarding her daughter pensively.

“She won’t wake up,” she complained.

I repeated the explanation that the nurse had given us in report earlier, that Carol had been medicated with Demerol.

“When did they give that?  And how long will it last? Something’s just not right,” she continued.

Her questions were good ones.  I set out to find the "real" nurse to explain the mother's concerns, but the nurse arrived at that moment with a syringe in hand to give Carol another intramuscular injection of Demerol for her pain.  The busy nurse briefly attempted to reassure Carol's mother before rushing back to care for her other nine patients.

As I continued to converse with Carol’s worried mother, I became uneasy. She described a high-functioning independent young woman who lived in a group home while attending a vocational educational program in the city.  Demerol or not, the Carol we were observing didn't fit the girl her mother described.

Carol occasionally writhed and moaned, seeming to struggle to wake as her mother tried to arouse her. Her breathing was audibly harsh with a frequent moist cough.  The family doctor was alarmed at her appearance when he made informal rounds to check on Carol.  He wasn't in charge of her hospital care which was in the hands of the attending physicians who were on staff at this hospital, but he asked that the chief trauma resident be called to see her right away.

Before the staff nurse could return to Carol's room, the senior trauma resident appeared at the bedside and started questioning me.  He examined Carol while I slipped out to get her nurse who told me she would "be there as soon as she could."

Awkwardly, I waited with Carol's mother as the resident considered Carol.  He wondered aloud why she hadn't gone down to the OR earlier as scheduled. I reminded him of the fever and as he listened to her lungs, I casually pointed out the petechiae, which was more diffuse across her chest now.

The resident was suddenly abrupt and to the point, it seemed he'd slapped the last piece into a puzzle. “She’s thrown a fat embolus from her fractured femur--get her to ICU stat.” Then he turned on his heel and was gone before I could say a word.

I had enough of the classroom experience in nursing to fear a pulmonary embolism (a tiny blood clot that lodges in the lungs), but I didn't have a great deal of insight into the prognosis and treatment for a fat embolus. The hours that Carol's condition had progressed undetected were haunting me.  Right away I knew that Carol needed her nurse, and I needed my instructor.

It took some time to find Carol’s nurse and convince her that the resident wanted her patient transferred to ICU.  She made the requisite phone calls to confirm the orders and set the wheels in motion so that the ICU would assign Carol a bed.  Meanwhile, Carol's chart was nowhere to be found.  It was misplaced somewhere on the surgical floor.  I nervously looked for the chart while the nurse arranged for Carol's transfer.

My instructor, aware of the unfolding drama, gave me a brief suggestion, "Just help where you can with the transfer." 

Carol's mother, numb with worry, was making phone calls to advise her family members of this turn of events.  A sense of urgency was consuming me as I returned to Carol’s room. Carol's nurse was still on the phone making arrangements for the transfer. Suddenly the resident reappeared and scolded me. “This patient should have been in ICU already! Get her there now!!”

But no such luck . . .  The nursing unit had their own procedures to follow.  They set about taking a complete set of vital signs, "It's required that we do so before transferring a patient." 

The nurse's aide who was trying to check Carol's blood pressure was having a hard time because, "This machine can't be right, her pressure's way too low." She went to search for a manual blood pressure cuff that affirmed the hypotensive state of the patient.

Carol’s nurse returned with a respiratory therapist who placed a pulse oximeter on Carol's cool, pale finger and advised, “She needs oxygen, her oxygen saturation is only 65%!”  Her saturation should have been at least 92.  The oxygen set-up for transport through the hospital to the ICU floor would have to wait for a few minutes while someone went looking for the missing key to the metal portable oxygen cylinder. The precious moments SLOWLY passed as these tasks to make Carol ready for transfer were completed.

I felt useless as the evening nurse and an aide prepared the bed for transport. “What can I do to help?” I pleaded. 

“You can carry the patient’s bag of belongings and make sure not to bring her flowers, she can't have them in ICU,” the staff involved in this whole situation seemed snappy and angry.  I thought it was a waste of brain cells for the nurse in charge to even think about the flowers under the circumstances. In retrospect, I'm sure I was sensing the staff's anxiety and concern, and I have to believe they all shared my frustration with the obstacles that slowed the transfer to what seemed like a crawl.  

My neck flushed as we awkwardly maneuvered the Carol's bulky hospital bed into the hall and then, after all the delays, ironically took off running for the elevator leading to the intensive care unit. There wasn't enough room for all of us on the elevator.  Carol's mother and I rode together on an adjacent elevator.

The small ICU waiting room was overflowing with visitors waiting to be allowed in to see other patients. I said farewell to Carol's mother and urged her to call her ex-husband to let him know what was happening.

I'd never before been through the sliding doors that isolated the large intensive care unit from the rest of the hospital. No matter, I found Carol’s room easily. Nearly every nurse in the ICU was at her bedside, hooking up monitors, taking vital signs, putting in an additional IV, preparing suction, and hanging fluids.  I could see the resident doctor with his interns assembling supplies.  In a few minutes time Carol would have a tube in her trachea that allowed a mechanical ventilator to breathe for her. 

I layed down Carol's bag of belongings lingered in the background for a few minutes. Clearly Carol was in good hands, these nurses were calm and in control of the situation. 

Suddenly my shift was over--it was time to meet my instructor and the rest of the clinical group before going home.  But I was sad and miserable.  I went beyond my required textbook reading that night. Fat emboli and acute respiratory distress syndrome (ARDS) consumed my thoughts. I grieved for Carol's mother and lamented that I hadn't known enough to help expedite her care that evening.

Two days later as I skimmed the morning paper, I was shocked--but not surprised--to see Carol’s photograph smiling brightly from the obituary column.  I cut that little clipping out of the newspaper and pasted it into my tiny notebook of nursing tips.  To this day I still carry that notebook in my nursing work bag.  I guess Carol's legacy has been with me every day that I've worked as a nurse, now that I think of it.

Technically, Carol was never "really" my patient.  No medication cards, flow sheets, or care plan followed me to her room that evening and my education and experience to that point certainly didn't prepare me for the gravity of her situation.  Of course, ironically, it was the deepest and most vivid clinical situation I experienced as a student. I always recognized that I contributed little, but benefited much from this experience.  Many of the lessons learned are so obvious that they don't bear repeating.  

An obvious lesson that does bear repeating, on the other hand:  never assume nor underestimate any patient's baseline mental capacity.  Good communication with a responsible party who can provide definite information on a patient's usual abilities is absolutely vital so that care is not compromised or delayed in the event of important neurological changes.  That's Carol's legacy to me.

All rights reserved 2009 Carolyn Cooper MPH RN

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