Friday, March 21, 2008

ready-set-go

I was on vacation from work for 15 days. IT WAS HEAVEN. But all good things must come to and end, right? Um, yeah, they do.

Last night was my first night back. As I got off the elevator the familiar, "welcoming" smell of cauterized flesh, charred skin, and topical antimicrobicals wafted under my nose. Sigh...

I went to the scrubex, got my scrubs, punched in, and headed into the locker room. I almost forgot my combination, but it soon came to me. I chatted with my fellow coworkers who were interested in hearing about my vacation and then I ventured out to "face my doom." To my surprise, staffing was okay, I had two relatively stable patients, well minus the ventilator and erratic junctional rhythm that plagued my patients on top of their burns. I no sooner finished getting report, when the charge nurse hung up the phone and paged me. "Don't get report, Kelly. We're changing the assignment, We've on 80%er." Eeks. Although I love the adrenaline rush of big, fresh, juicy burn, the anticipation can be overwhelming. I tried to get more of the history, but we didn't have a lot of information. the patient was being seen by the fellow and resident down in the ER, the ER nurse was going to be calling up report, but I needed to move fast and set up for a long night ahead.

As that thought crossed my mind, my stomach gave me a little rumble. Guess I should have eaten those eggs I hard boiled at home.

I set off to the supply room in a fury..gathering all my supplies, setting up central lines, prepping for an arterial line, anticipating the needs for a salem sump nasogastic tube insertion, finding all of the supplies to do burn care, paging respiratory to bring me a ventilator, etc. My hands were full, my heart beat was quick, my steps rapid. Game on folks!

I no sooner had everything set up, when the ER called up. I took report. 88 year old female with 95% TBSA (total body surface area) 3rd degree burns-yikes, worse than I thought. Pt was intubated in the ER and currently having an A-line placed. Vitals signs, not so stable; Respiratory status, shitty;core body temperature, 31.1 (that's88 degree Fahrenheit); chance of survival, less than 2 percent. She'd be arriving on the floor in 15 minutes.

Exactly 15 minutes later (shocker, I know! ER time estimates are never accurate) my patient arrived via stretcher being bagged by the respiratory therapist, attached to the portable cardiac monitor, and accompanied by one of our burn fellows. Hmm, gotta love that smell. Charred flesh, and lots of it. Immediately, we transferred her to the bed, hooked up all her lines, started a versed drip, continued to pump her with her Parkland Burn Formula fluid requirements (22Liters in 24 hours. Her temperature 31 degrees. With each degree that her body temperature dropped, so does her chance of survival. WE ran all her fluids though the fluid warmer, placed her under the heat shield and bair hugger. Building engineering increased the temperature of her room to 80 degrees....thank god I remembered my deodorant!
This poor woman was a mess. Her extremities were like icicles to the the touch, her skin beginning to swell as we pump her massively vasodilated circulatory system with fluids, her blood pressure remained low, her heart rate high...all signs pointing to being intravascularly depleted and dry. We couldn't do burn care, she was too cold.

The woman had no family, but her power of attorney was on her way in from New Jersey with the patients living will. Until then, we just had to wait. I ran around hanging fluids, pushing meds, sending of arterial blood gases and blood work, but she wasn't warming up. I sent off her blood to get a metabolic profile with all her electrolytes, but she was so cold and vasoconstricted that the blood kept hemolyzing and we couldn't get a reading. I thought attempt #4 would be my lucky shot, but I no sooner sent off her labs, than I got a phone call from the lab that the top popped off and the sample was lost. What the hell?!?! I can't keep drawing blood off this patient, she's not stable enough for the circus. I gave it one more shot, finally success.

As I was finishing the priest came to administer last rites, the patients last request before she was intubated. Yes, that's right. She was awake and alert for almost 2 1/2 hours. As the priest prayer with/over the now sedated and vented patient, I felt calmed, like if the woman was to die (on this Good Friday) that she would be at a spiritual peace. After the priest left, 3 different neighbors came to pray the Rosary over her. I was touched.


At 1am the health care proxy/power of attorney arrived, looking shaken and upset. I went with the fellow and we gently talked with the woman outside the room. After calling the administrator on call and the attending, the patient was made DNR with no escalation of care. I sat with the HCP (turns out she's the patients god-daughter) and let her know that I would continue to remain available to them if she had questions or needs over night. She thanked me and left.

By 4am, the woman had only put out 4 cc's of black turbid "urine". Quick little bit of math for you: 15 Liters (15,000cc) of fluid in, 4cc out, = 14996net. Kidneys have shut down.

Around 5am her respiratory status really started to decline. Her lungs were filling with fluid and her circumferential chest burns weren't allowing her lungs and chest wall to expand. Aside from changing a few settings on the vent to force some of the alveloi open, there wasn't much we could go. The waiting game began.
Soon to follow, her blood pressure took a hit and her heart rate continued to rise. She wasn't perfusing her extremities. She was loosing body heat again.My heart sank. I stood there and said a quick prayer.

By change of shift, her prognosis was grim and it was torture giving report to the say nurse. It was futile. I felt like I was handing over a corpse. As I walked off the unit Friday morning, I wondered what the day would bring for my dear patient. I went home exhausted. I realized that I hadn't been to the bathroom in 13 hours, but then again I hadn't drank anything either...and that's why my urine was almost the color of tea. Sorry if that's TMI.

Despite the exhaustion, I couldn't sleep. I tossed and turned. Around 1:30 I got up and went running. It was good to clear my head, I needed that.

As I walked back onto the floor Friday night, I heard the overhead page. "Nurse taking care of pt in room XXX please indicate. Transport is here."

And so it happened. She died. The day nurse reported to me that the family decided to withdraw care and remove the patient from the ventilator around 4:XXp.m. She died 8 minutes later.

I'm not sure if it was because this is Holy Week, or because it was my first night back after a glorious vacation, but I do know that Thursday night affected me. We need to cherish each and every day because the only guarantee in life is that there are no guarantees.

2 comments:

O said...

Wow. What a return to reality. That poor woman--88 years in this life and ending with 2.5 hours in such massive pain, I can't even imagine. What she went through to get those last rites! I'm glad some who loved her--including you--were with her at the end.

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