I walked into work last night at 18:30 with a giant smile, hidden under my mask of course, and a pep in my step. It was night 3 if 3, but it was going to be a great night, I proclaimed! Because I had woken up to a full pot of coffee already brewed and waiting for me. Nothing a night shifter loves more in life than coffee.
I even had to brag about making all 26 assignments that morning and not having a single person complain to me or ask me to change their assignment— either before or after start of shift. It was unprecedented, and I was feeling pretty good about myself.
Fast forward only a brief 30 minutes and three people were asking to go home at 23:00 if we were overstaffed, and a hospital that had accepted a transfer patient tried to refuse once we called to tell them that the transporters were about to leave and the ETA was 45 minutes.
We solved that problem but then also kept busy for the next few hours with transferring 2 more patients out of ICU, providing end of life care for an end stage liver disease patient whose illness surpassed her body’s ability to fight back, and we accepted 3 admissions from outside hospitals and 1 admission from the emergency department. Not to mention making sure all 25 nurses on duty get breaks…
The next 8 hours didn’t get any easier. There were multiple simultaneous rapid response calls (RRTs) with one that turned into a Code Blue. We accepted and then un-accepted more transfers because we kept getting calls for more urgent cases. We had a way-too-young patient brought to us after a out-of-hospital cardiac arrest with several more in-hospital cardiac arrests (all in a short time frame) that needed ECMO placed for full heart/lung failure. Because of this, we had to refuse a Tylenol overdose in liver failure, also a life threatening condition—but not as time sensitive at that moment.
Another unexpected transfer from an outside was a patient with recent cardiac surgery who had suffered a stroke and whose brain was swelling. This patient needed emergency neurosurgery but was at a hospital without a neurosurgeon.
Luckily, by which I mean not, we had already been waking up the neurosurgeon frequently because one of his other patients with a hemorrhagic stroke was also having some pretty serious problems. Her ICP kept rising, and she was starting to have cardiac complications from the myriad medications we were using to keep her from bleeding into her brain more. Her heart was having 15 second “pauses” which honestly, is enough time to almost make everyone else have a heart attack.
While adjust her medications so that her heart stopped stopping, just 2 rooms down, a cardiology patient admitted only the night before was decompensating as well. She came in with what was presumed to be heart failure and fluid overload. But upon closer inspection also appeared to be harboring severe signs of sepsis. There was a battle going on however between what we as nurses could see going on with patient and what the cardiology team wanted to do.
Also, we had an unfortunate problem in this case. A family member who is a cardiologist, and actually a cardiologist who trained at our hospital but now works elsewhere, wanted to 100% dictate the care. And they let her. She chose the attending cardiologist, she set the treatment plan. There was to be no changes.
To make a long story with a lot of history and precedent much shorter: The patient was DNR. Her heart rate, which had been in the 120s to compensate for the infection and cardiac issues she was having, dipped to the 60s and then quickly into the 30s. At this point she had no pulse and was having a PEA arrest (pulseless electrical activity). Someone called me to the room by literally screaming to me as I valiantly tried and failed to get a cup of coffee. I got to the room as a young baby doctor with fear in her eyes stuttered indecipherable things while looking at her phone.
The nurse whom I trust implicitly looked straight at me as I entered the room and told me what I needed to know as I saw her heart rate. “She’s a DNR.” The nurse is calmly standing on one side of the bed, hand on where the patient’s radial pulse would be, if she had one. I cross to the other side, take the patient’s hand. She is cold, not breathing. The heart rate on the telemetry monitor reads 33 but the heart is not actually pumping. There is not pulse. Another nurse comes in to help and I shake my head no to her as she looks at the monitor.
The doctor is on the phone with her supervisor asking about pacing or this or that. We close her eyes. Take off the oxygen mask, turn off the IV medications and disconnect them. I look at the doctor as she gets off the phone. I shake my head. At this point, we have turned off the patients monitor. There was no longer any visible vital signs.
As the doctor leaves the room to call our patient’s family, we begin washing her. This is a most important step for us to take to give dignity and pay respect to those who pass away in the confines of the ICU.
But it is only 04:00. It will be more than 4 hours before I leave at the end of my shift. In that time, I send 2 more nurses on break. I review the charts for 25 patients. 2 admits arrive to settle in. And I give report on I-don’t-even-remember-how-many-patients-we-ultimately-ended-up-with to the day shift.
And it all started with me bragging about what a great day it was going to be because I woke up to a fresh pot of coffee already brewed for me. Also, we literally checked if it was a full moon at one point. It wasn’t— it was a new moon. So it was my fault. I’ll take the blame this time.
I’m still left to wonder though: why are nurses so superstitious???