Saturday, May 5, 2007

Mary K & and Terrible, Horrible, No Good, Very Bad Day

We made bedside rounds that morning and one of the patients TOW'd from the ICU two days earlier was reporting a headache. Since that's one of my specialties, I asked, "Is this headache like headaches you've had before?" She said yes, and she treated it with Tylenol. We promised to get her relief. The plan was to discharge her home the next day.

Subconsciously we knew she just wasn't right, because everyone checked on her frequently. She started vomiting and told us it was related to the headache. Her only PRN medication besides Tylenol was MOM. She refused offers for us to get Zofran or phenergan. The doctor had ordered a doubling of her lisinopril dose and I reviewed the side effects. I went back to her room.

"Have you been taking lisinopril long? Did your headaches start with the addition of lisinopril?" She considered the question, and said no, the headaches started long after that. She was sitting in the chair, leaning her head against her hand, resting her elbow on the rolling table. "How bad is the pain?" She replied, "It's a 2." I went back to the med room and saw that I could at least give her another dose of Tylenol.

She never got it. When I returned to her room, the ward clerk was holding her hand and calling her name. She was splayed out in her chair, with her head at an odd angle. She was on telemetry so I ran for the bat phone to the ICU and told the listener on the other end to start recording strips. The LPN called for a code. The corpsman and I raced the crash cart down the hallway. We dragged her chair over to the bed where we lifted her up and laid her flat, her eyes open wide and drool running from the left side of her mouth. We opened the crash cart as the code team came up the back ladderwell from the ER. The other floor nurse was assisting with the efforts, so I stayed outside the room and managed the rest of the floor.

Another patient's oxygen saturation levels were dropping to the low 70's. His ABG's showed severe acidosis and the hospitalist went in to deliver the bad news to the patient and his wife. My patient had a final request so I had the legal officer get a lawyer from Big Navy to come and do a deathbed will. I witnessed his signatures on all the forms and when we were done, they had already taken the other patient away.

Without the bed, the room was cavernous. Crumpled 4x4 gauze and blood smeared the floor where they started an EJ instead of wasting time searching her non-existent antecubital veins. A freshly spiked and primed infusion set dangled on the edge of the trash can, unused. The chair had been shoved into the corner. It was a rave gone bad.

Back when I first started nursing, one of my intern friends coined a term: the Grillo sign. Practically everything in healthcare is objectively measured or assessed and identified by signs---Obturator or Psoas Signs, drawer sign, or Homan's Sign. For Dr. Grillo, this meant the radiologist didn't have to point out the abnormality on the films; the defect or problem was readily apparent, often at some distance from the viewer.

This patient stroked out. The signs were there. She'd reported nausea over the past few days and other non-specific or vague symptoms. Only a few tools exist for treating stroke on Guam: medications like mannitol to reduce brain swelling and vasoactives to control blood pressure, drilling holes in the skull to relieve swelling (a very bad sign), and prayer. These patients are not stable enough to medevac to Hawaii or Japan. And rehab is extremely limited for those who survive.

Would identifying her problem earlier have made a difference? I repeated this story so many times that day, to myself and to others who patiently listened, who must have been reminded of "what ifs" in their own careers as healthcare professionals. As others reassured me, everything had already been set in motion long before I assumed her care that day.

Ultimately, the long slow bleed filled the right ventricle of her brain. And now, it is a waiting game, as it is for the patient with lung cancer, while we wait for the next terrible, horrible, no good, very bad day.

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