It was the start of the last of my usual three twelve hour weekend shifts that I work during the night in a medium sized ICU.  I had just taken report on a middle aged male who had had a blockage removed from the arteries of his heart the previous evening.  He was stable and should pose no difficulties with my main goal of having him sleep through the shift as undisturbed as possible.  Working the night shift, I truly value giving my patients the opportunity to sleep knowing very well the problems caused by sleep deprivation.

My other patient was a female in her sixties.  She had been admitted during the week for low blood pressure, diarrhea, weakness, and anemia.  Her history was complicated by renal cancer that had spread to her left shoulder and possibly to her abdomen.

I had taken care of the female patient over the previous two shifts.   Her blood pressure was marginal on the first shift I had had her and I had given her blood to correct her anemia and to enhance her blood pressure.  That had been successful and the next night was spent monitoring her blood pressure and assisting her up to the bed side commode.  There were no visible signs of blood in her stools and the cause of her anemia remained uncertain.   Fortunately, her blood pressure remained stable and there were no other indicators of acute bleeding during the shift.

During my first encounter with the patient I asked her what she did when she wasn’t in the hospital.  This is my stock question to patients who can talk (they often can’t) and I feel it gives me a chance to know the patient as someone other than “a patient” and the patient to think about something other than the hospital.  The female patient’s response was terse and almost hostile.  She said, “I’m too sick to do anything” and that was the end of her response.  Not wanting to engage in any more unpleasant conversation, I kept my verbal interactions with her to a minimum.  During the first two shifts with her, though, I began to understand why she was so terse.  Her poor buttocks were extremely raw from weeks of diarrhea and it was painful for her as we applied a thick zinc based lotion to them after every trip to the commode.  And then getting back to bed was a major travail as a Patient Tech and I struggled with her swollen feet, lower legs, and abdomen and her sore shoulder.  Although she was obviously miserable, she did was stoic and did not whine.  I gave her medication for pain, and after we had situated her in bed, with pillows supporting her sore shoulder, she slept between her trips to the commode.

This evening I started to take report on the female patient from a different nurse than to whom I had given report that morning.  Amy had gone home earlier, so Jane had taken the patient for the last few hours of the day shift.  The female patient had had a seemingly unremarkable day.  I could see that she was sitting up in the chair in the room and her husband was beside her.  They were both watching TV.  That was good. 

But then Jane discussed the patient’s oxygen saturation over the day.  Oxygen saturation is a crude measure of how much oxygen is being delivered to the various organs, tissues, and cells in the body by the red blood cells circulating throughout the body which receive oxygen in the lungs.  Without enough oxygen, the organs began to malfunction and die, eventually leading to the death.  At 5,000 feet, a low, acceptable oxygen saturation is 90 percent.

Jane said that the patient’s oxygen requirement to keep her oxygen saturation at or above 90% had gone from 4 liters a minute to 16 and the oxygen was being delivered by an oxymizer rather than a simple nasal cannula into her nose.  An oxymizer is more efficient at delivering oxygen and that meant that the patient’s oxygen needs had gone up dramatically since that morning.

I was concerned about this and as soon as report was completed, I ran into the room to turn off the patient’s IV fluids.  The IV fluids were being given because the patient had not been taking much oral fluids during her previous days in the hospital.  Today her oral fluid intake and urine output was satisfactory and there was a physician order to stop the IV fluids if this criteria was met.   My specific concern was that the patient’s increased oxygen needs might be due to increased fluids in her lungs and if that was the case, she didn’t need the additional IV fluids.

After I turned off the IV fluids, I quickly listened to the patient’s lungs with my stethoscope.  I could hear crackles in the bases of her lungs that had not been there the previous evening.  That, along with her already swollen lower extremities and increased oxygen needs indicated that the patient was likely in pulmonary edema, or more simply, that she had a great deal of fluid in her lungs.

The rising oxygen demands of the patient had not gone unnoticed during the day shift.  That morning she had been given 20 milligrams of IV furosemide, a diuretic, in the hopes that would increase her urine output and pull off some of the fluid from her lungs and reduce her oxygen need.  The dose was relatively small, but there was a concern about giving too much furosemide which might cause too much loss of fluid and cause her blood pressure to fall excessively.  The patient’s low and marginally low blood pressures during most of the initial three days she had been in the hospital warranted these concerns.  Fortunately, during the day shift the patient’s blood pressure had remained in the normal ranges but her urine output for the shift was only 500ccs, or roughly 17 ounces.  When one considered that she had been getting 75ccs an hour of IV fluids through the shift and had drunk at least 500ccs of fluids, this was further cause for concern.

After briefly checking on the female patient, I went to assess my year old male patient in his 30s.  He was a big guy.  His vital signs were stable, lungs were clear, his monitor was showing a normal rhythm, and the site where the cardiac catheter had been inserted looked good.  He was pleasant, tired, and just wanted to sleep, which was fine with me.  I wrote down his vital signs and headed off to record my assessment in the computer.

Just as I finished recording my notes on the male patient, the female patient asked to return to bed.   Thinking back on the previous night, I asked her if she needed to use the bedside commode first and she agreed.  This would maybe save us a trip later on in the shift.  Sheila, the Patient Tech, came in to help.  We removed the monitoring cables from the patient to facilitate our trip and slowly assisted the patient over to the commode, which I pulled behind her as soon as she cleared the chair.  The patient’s husband, who had been sitting with her, moved to the front of the room and we pulled the curtains so she could have some privacy.  I sat in my module next to the room and continued with my charting on the computer.  In a few minutes the patient asked to go back to bed.

Sheila and I slowly got the patient up, cleaned her up, applied a thick coating of protective lotion to her poor, red buttocks and slowly and carefully moved her back into bed.  When she was in bed, we used the draw sheet like a sling to move her head to the top the bed, elevated the head of the bed, and put pillows under her sore left shoulder and arm for support and comfort.  At the same time, we put back on all of the various monitoring wires and cables.

At this point, the reader might wonder why in an ICU you would take off the monitoring cables while the patient was on and transiting to and from the commode.  My answer to you would be safety and sanitation.  The patient had been relatively stable.  She also weighed more than Sheila or I.  The monitoring cables posed a hazard in tripping the patient, Shelia, and I during the transfer and extending the amount of time involved in the transfer.  Further, monitoring cables have been known to encounter the contents and the residue left on the seat of commodes during transfers of patients, especially patients who are not very steady on their feet.  I would rather not have that happen or have the patient end up on the floor.

Things did not look good when we got the patient back on the monitor.  Although we had left her oxygen on during the voyage to the commode and back to bed, her oxygen saturation was hovering in the mid 70% range when it came up on the monitor.  Low normal for a person living at 5,000 feet is 90%.  Fortunately, her BP was fine and there was nothing unusual on the heart monitor.  As I expected, her nail beds and lips were blue.  Her breathing rate was in the 40s.  Normal is 10 to 20. 

The patient’s husband returned to the bedside and watched his wife struggling to breathe.  I was relieved that he didn’t ask me a bunch of questions about why his wife was having such a hard time breathing or about the flashing red numbers on the bedside monitor.  As I write this now, I believe he already was very aware of how gravely ill his wife was.  I returned to the computer and quickly worked on completing the mountain of charting on both of my patients that is part of the ritual at the start of the shift.

My thinking was that the patient had used what little oxygen reserves that she had during the trip to the commode and that her saturation would improve when she had a chance to rest and catch her breath.  Nevertheless, when the patient was settled in bed, I put an oxygen mask on the patient, in addition to the cannula in her nose, and cranked both up to the maximum rate.  I also set up an ambu bag for immediate use should we need to manually force oxygen into her lungs and checked to make sure we had oral suction available should we need to clear her airway.

As I was charting on the computer, I was looking up several times a minute to see if the patient’s oxygen saturation was improving.  The sats were still in the low 80s and her respiratory rate remained in the high 30s.  I called one of the Respiratory Therapy, RT, staff to ask if they could check out the patient and improve her breathing status.  The RT person I talked to said she was busy with another patient in a breathing crisis but that she would send another member of their staff up to check out the patient.

Vicky from RT arrived in a few minutes.  The patient’s status had not changed and Vicky went to get a Bipap unit.  The Bipap is a machine that can force pure oxygen under pressure into a patient’s lungs through a mask that is held tightly in place over the patient’s nose and mouth.   It was our hope that the Bipap would help the patient get over her breathing crisis or at least buy us some time.  The next step would be putting a tube down the patient’s throat and placing her on a ventilator if the Bipap didn’t work.

Although ventilators are a ubiquitous part of the care of ICU patients, I dislike them.  The ventilators that are available now are far better than the ones we used in the early 1980s when I first started working in ICUs.  But, the fact remains that having a large tube going down the throat into the trachea is an extremely unpleasant experience for the patient.  Most patients require a great deal of sedation to tolerate the experience and diligent and frequent care must be provided to prevent serious complications.  With patients who have serious, preexisting disease, getting them off the ventilator can be difficult, if not impossible.  It can be an extremely depressing and frustrating experience for the patient, their family, and the health care staff providing care.  Some patients die from complications while on the ventilator and others must be eventually transferred to long term facilities that specialize in ventilator care after they are on the ventilator for several weeks.

Vicky got the Bipap set up on the patient in a few minutes and the patient’s oxygen saturation started moving up into the high 80s, a good sign.  An in house physician who I had paged called me back.  I quickly reviewed the status of the patient with the patient and advised her that I was getting a stat chest x-ray to hopefully give us an idea of why the patient was having such difficulty breathing.    She agreed with what we were doing for the patient and said she would be up to examine the patient soon after she had completed admitting a patient in the Emergency Department.

I was relieved to see that the patient’s oxygen saturation had moved up into the low 90s after I finished talking to the physician, although her respiratory rate was still in the high 30s.  I could see that the patient was trying to write a note to her husband; it is very difficult to talk when you are short of breath, especially when you are on a Bipap machine. 

The patient’s husband brought the note out to me.  He said that the patient wanted to have surgery for her kidney cancer as soon as possible.  He then went on to say that he was going to leave.  I thought it was a bit odd that he was leaving when his wife was in such obvious distress, but I was too busy with other issues to question his decision.

The patient had been seen by a surgeon the previous day concerning surgery for her kidney cancer.  She and her family had been told that the surgery would only be palliative, that is it would only reduce some of the severity of the symptoms of her cancer because it had already spread to other parts of her body.  Further, the surgeon felt that the chances of major complications from the surgery were about 50 percent.  I had been told by one of the day nurses that the patient had been unsure about whether to have the surgery and that one of the patient’s daughters had wanted to go through with the surgery, but the other felt it was not a good idea.  Both the day nurse and I agreed that the outcome of the surgery would likely result in a long and miserable stay in the ICU for the patient with a high probability that the patient would not leave the ICU alive.

Surgery at this point, though, was out of the question.  The patient was far too unstable.   I did not discuss this with the patient or her husband as I was very narrowly focused on getting the patient through the shift alive.  Two people from X-Ray came to the patient’s room and I helped them do the chest x-ray on the patient.

Another physician, Barry, called me back in a few minutes.  He said he had spoken with the physician in the Emergency Room and reviewed the patient’s chart.  He had noticed that the patient had gained 30 pounds of weight since admission and he felt the cause of patient’s breathing difficulties was likely fluid in her lungs.  We agreed that I should give her 40 milligrams of IV furosemide immediately and that he would be up to the review the chest x-ray of the patient in a few minutes.

As soon as I got off the phone, I put the order in the computer and gave the patient the furosemide.  I then tried to give the patient several oral medications that were scheduled for that evening.  My efforts were futile.  The patient already had difficulty swallowing pills and could only swallow them if they were cut into small pieces and if she swallowed the pieces one at a time with water.  I tried this once and her oxygen saturation dropped into the 70s because we had to pull off the Bipap mask to get the pills and water into her mouth.  None of the medications were essential for the moment, so I put that task on the back burner.  

I was relieved that by 9 p.m. the patient had put out 60ccs of urine during the previous hour.  At 10 p.m. she had put our 150ccs.  Her oxygen saturation was between 90 and 93 percent.  But her respiratory rate was still in the high 30s.  Her blood pressure and heart monitor pattern remained stable.  She was awake and obviously fully focused on breathing.

Barry came up to the ICU.  He said the x-ray had confirmed that the patient was in pulmonary edema.  Since her blood pressure wasn’t dropping, he ordered 100mg of furosemide to be given now to increase her urine output and, hopefully, decrease the amount of fluid in her lungs.  At the same time he said that he would order some IV morphine and IV lorezapam to calm the patient and, hopefully, reduce the work associated with her breathing.  We also discussed the surgical consult that the patient had received and that the patient and the family had wanted everything to be done for her.  She was not a DNR, or Do Not Resuscitate, meaning that at this time, everything was to be done to keep her alive.

I was concerned about giving the patient any type of sedation at this point.  The sedation might just push her over the edge where she slowed her rate of breathing and with that, dropped her oxygen saturation.  That, in turn, would require her being placed on a ventilator.  I discussed my concerns with Barry and we agreed that I would start by giving the patient small doses of morphine.  Morphine has a much shorter duration than lorezapam and can help reduce pulmonary edema.  I went to get the morphine and Barry went off to try to contact the patient’s family and see other patients.

My male patient continued to sleep soundly through the shift with the only problem being his heart rate was going into the 50s and triggering the monitor alarms.  This is normal was not abnormal for a middle aged male while asleep, so I adjusted the alarms trigger down to 45.  Why have an alarm for a condition that is not worthy of your attention?

The furosemide started to kick in on my female patient and she began to make 300ccs of urine an hour.   I had given her some small doses of morphine and this had not depressed her respiratory rate.  Her oxygen saturation remained in the low 90s and her BP was stable.  Whenever we took off the Bipap mask to give her a few sips of water, her saturation rapidly fell into the 70s.  We were not going to get her off the Bipap any time soon.

Around 1 a.m. Barry and I talked about the patient.  Her BP remained stable, but her oxygen saturation was hovering in the very low 90s and often was in the high 80s.  This was not good.  He ordered and I gave another 100mg of furosemide with the hope that the increased urine output would eventually help her breathing.  The RT staff had placed the equipment immediately outside the room to place a breathing tube into the patient and allow the patient to be placed on a ventilator should her breathing status deteriorate much further.

Barry said that he had been trying to contact the patient’s family to talk about her breathing problems, but had only been able to contact one of her granddaughters.  It turned out that both the patient’s daughters and her husband worked at night.  It was obvious that Barry was reluctant to place the patient on a ventilator unless the patient and her family insisted on it.

Around 2 a.m., the patient’s oxygen saturation was staying in the mid 80s.  Barry had finally contacted one of the patient’s daughters who was working at a Wal-Mart.   She was coming to the hospital and had asked that we not place her mother on a ventilator until she had a chance to talk to her.  She was going to try to contact her father and her sister to tell them about her mother’s deteriorating breathing status.

The patient’s daughter arrived roughly an hour later followed by her other daughter.  Barry talked daughters and they agreed that they did not want us to resuscitate the patient if her breathing or heart stopped and we were not going to place their mother on a ventilator.  The patient agreed with this decision.  At that point the patient’s oxygen saturation had moved into the low 80s.  The daughters moved in and out of their mother’s room to be at her side and worked to contact her father.  It turned out that he worked as a night watchman at a nearby factory and was difficult to contact while at work.

I was relieved that the daughters had not become angry or extremely upset over the condition of their mother.  In these types of situations, caring for upset and sometimes unruly family members can interfere with the care of the patient.  I got the daughters some coffee and thanked them for coming to the hospital.   It was a relief to me that they were here with their mom who needed them far more than anything I could provide.

Around 4 a.m. the daughters finally contacted their father.  He was the only person at the factory and said he could not leave until he contacted his supervisor and found someone to cover for him.  In a way, I admired him for his dedication to his employer but also wondered if he fully understood how direly sick his wife was.  She might stop breathing and die at any moment.

About an hour later, the hospital Chaplain arrived to be with the family and maybe 30 minutes the husband arrived in his night watchman uniform.  He cried when he reached the bedside of his wife and hugged her.  Despite her oxygen saturation being in the 70s, she was still awake.  More family members arrived and settled at the patient’s bedside.  The Chaplain organized the family in prayer around the patient.  I can’t describe how thankful I was that the Chaplain was there to assist the family through this situation.

Soon after the patient’s husband arrived, the family asked that we remove the Bipap machine.  As I indicated earlier, it is almost impossible to talk with a Bipap mask on and it can be very uncomfortable to wear.

At first, I felt reluctant to take off the Bipap mask.  The Bipap had gotten the patient through the past 10 hours.  Taking it off would mean that the patient would likely die in the next few hours.  Although I have had many patients die during the over 25 years I have been a nurse, the experience still bothers me at a very deep level.   I find that platitudes debase the very personal nature of death and avoid them.  Consequently, I am usually at a loss for words in these situations.

 I went into the room with many family members around the patient.  With the family’s help, I pulled off the Bipap mask, switched off the machine, and placed an oxymizer in the patient’s nose with the oxygen running at maximum flow.  The patient’s family helped the patient sip some water.  The monitor alarms at the bedside were going crazy and so I turned off the monitor.  Why do we need a monitor to scream about something which we are not going to fix?

It was nearly 6 a.m.  The shift would end in 90 minutes.  I went about doing the end of the shift tasks for both of my patients.  When those were completed, I sat down outside of the female patient’s room and pulled out The New Yorker Magazine and continued reading an article about Zimbabwe that I had been reading in fits and starts through the shift.

Shortly after that, the Chaplain came up to me.  She asked about giving the patient some morphine and lorezapam to calm the patient.  Her request initially stunned me.  I told her that I was afraid that giving either one of the drugs might cause the patient to stop breathing.  As I talked to the Chaplain, my mind had to do a summersault to appreciate that now our goal was to ensure the patient’s comfort and calm rather than to keep her alive, as we had struggled to do during most of the shift.

I got the drugs and went into the patient’s room.  She was working to breath, but still able to talk to her family members at the bedside.   The patient’s skin was very pale and cool.  Her lips and nail beds were a light blue purple color.  I told the family members what I was doing to verify their consent and then pushed the morphine and lorezapam through the IV line.

The nurse for the day shift arrived shortly after 7 a.m.  I started giving status reports on both of the patients I had cared for during the night.  The phone rang and it was the Cath Lab calling to say that they would be taking the male patient down to the lab in a few minutes, along with a list of things that needed to be done before they arrived to transport the patient.  The day nurse and I went to the male patient’s room and prepared the patient for the Cath Lab while I gave her a quick report on the patient. 

As I left the male patient’s room, one of the female patient’s daughters rushed up to me saying that she thought her mother had died.  I hurried to the room and examined the patient.  She was very still.   I could not see any rise or fall of her chest.   I tried listening to the patient’s heart with my stethoscope.  I could not hear any sounds from her heart.  I tried to feel for a pulse along side of the patient’s neck, but could not detect one.  Again, I thanked the gods that the Chaplain was in the room with the family.

I walked out of the patient’s room and fortunately one of the physicians rounding on the patient that morning was there.  I talked to him briefly and he agreed he would pronounce the patient dead and then he went in to the patient’s room to talk with the family.  I quickly typed a noted into the patient’s chart concerning the patient lack of breathing, heart sounds, or pulses.

I had a short, pleasant exchange with one of the patient’s son-in-laws before leaving to go home.  We shook hands and I went to the break room to get my coat.  The sun was shining in the cool, fall air and there was snow on the mountains to the west as I walked out of the hospital.  The shift was over and I was relieved that I had the next four days off.