Lives in the Balance: Nurses' Stories from the ICU

by Tilda Shalof

  When Mr. Abruzzi had been off the ventilator for over a week, we started him on a trache mask, which delivers a flow of humidified oxygen to the trache through the open hole, or stoma. His wounds were actually beginning to close, from deep within the narrowing gaps. We could see healthy granulation tissue, and the edges had begun to approximate. When he had been independent of the ventilator for five days straight and was able to cough up his secretions well, he no longer needed the ICU. We transferred him to the step-down unit and a few days later he went to the floor.

  Less than a week later, Mr. Abruzzi went into cardiac arrest.

  Late in the afternoon, I heard “Code Blue, Code Blue” on the overhead announcement system. I had just transferred my patient to a floor so I knew I’d be next in line for the new admission—if this arrest patient made it, I figured, he or she would be mine. I went to prepare the room, just in case. I never expected it to be Mr. Abruzzi.

  Once again he was in septic shock but now he had, in addition, a hospital-acquired infection called Clostridium difficile. I gasped when I saw him, just as I had when I first met him, but this time not at the horrific sight of his wound; rather, it was the shocking condition of his whole body. The man I had cared for and come to know had become huge, his body taut with fluid, swollen with infection. I had to check his name band to be sure it was him.

  “Giovanni!” I called into his ear. “Wake up! Squeeze my hand.”

  There was no response.

  Tracy, one of my closest friends—we’ve worked together for years—came over to me: “The lab called. His potassium was 2.9 at 1300 hours.”

  “A potassium of 2.9?” I repeated. How was that missed? Tracy and I looked at each other, then down at Mr. Abruzzi. He was a dusky gray. His limbs were cold and mottled. He was putting out only drops of urine. His dressings were soaked with yellow drainage. The most critical problem was his hypokalemia. Serum potassium levels must be kept within a strict range, usually around 3.5 to 5.5 meq/L. Too high or too low can cause dangerous arrhythmias. A potassium of 2.9 could definitely have lead to a cardiac arrest.

  Tracy went to check the rest of the lab values on the computer while I prepared a bolus of potassium chloride, a common drug that can be lethal if administered incorrectly, but is lifesaving in circumstances like these. I asked Tracy to double-check the bolus before I gave it, as we always do, especially with powerful drugs such as potassium chloride, heparin, insulin, and others. Twenty milli-equivalents of potassium chloride is the maximum dose that may safely be given in a peripheral vein over a one-hour period, I had memorized from the medication administration policy manual. Mr. Abruzzi needed more than that, but a larger dose requires a central vein, which the ICU doctor was preparing to insert. For the present, I had only a peripheral IV to use, to begin replacing this essential electrolyte.

  Tracy scanned the rest of the lab values and called out the numbers. “His pH is 7.10 and his lactate is 7.5.”

  Those are terrible numbers. Mr. Abruzzi was in a serious metabolic acidosis, likely due to infection. It was probably not just in his leg, but throughout his bloodstream.

  His daughter came in, sobbing. “The nurses caused this!”

  I greeted her but kept my head down as I removed one of the IVs from her father’s arm. It had gone interstitial, meaning it had slipped out of the vein. I didn’t answer her, not only because I didn’t want to incriminate my colleagues, but because I knew that a number of things had gone wrong here and many people were responsible. Also, I knew that this situation was more complicated. No, the nurses hadn’t caused it, but they could have prevented it. If things were different on the floor, nurses would have been onto this problem earlier and done something about it. Nurses could have kept this patient safe.

  “The nurses let this happen,” she said. “Why didn’t they do something?”

  I prodded around Mr. Abruzzi’s arm, avoiding her eyes and her question. I focused on searching for a vein into which I could insert a new IV. He needed fluids and antibiotics, possibly inotropes, too, I thought, as I noted his dropping blood pressure.

  “The nurses caused this, don’t you agree?” She kept hounding me.

  I looked up. “How did the nurses cause this?” I finally asked because that seemed to be what she wanted me to say.

  “Last night I wanted to come in to see Dad, but I couldn’t; I had the kids with me and everything. But I called and the nurse said he was agitated and disoriented—and that’s not like Dad. I know he’s almost seventy and all, but you know how sharp he is. He has all his faculties. ‘What are you doing about it?’ I asked the nurse. You know what she said? She said, ‘I’m documenting it.’ Well, good for you but what are you doing for my dad?”

  How well I know those evasive charting terms. M.D. notified. Problem charted. As nurses we’ve all done this when we’ve felt helpless, or that no one was listening to us, or when we were afraid to speak up. There were so many explanations for this inertia, this passivity: entrenched hospital hierarchies, sexism, inadequate nurse-to-patient ratios, disempowered nurses, and on and on. None of them justifiable, but still, these conditions are part of the stultifying environment and harsh reality that still exists in many hospitals today.

  I remembered what it was like to be a floor nurse. So many times I felt overwhelmed by the workload dumped on me. I felt voiceless and invisible. At times nurses are demeaned, even bullied, by arrogant doctors and sometimes also by fellow nurses. The hospital can be a very inhospitable, even hostile, place. You see something that worries you about a patient, but no one will listen to your concern. You have questions, but there’s no one to ask. You know what the patient needs, but you can’t do it; your hands are tied. You know what to do but are afraid to be wrong or challenge the doctor. You call the doctor. You wait for the doctor. You pray the doctor will listen to you, take you seriously. I knew all of these situations so well because I had been in every one of them myself, earlier in my career.

  Mr. Abruzzi’s daughter continued her rant; I just listened.

  “They neglected him. I don’t think a nurse looked in on him all day,” she said.

  If that is true, it is terrible and wrong, but I had done similar things—and worse—when I worked on the floor as a newbie nurse. I’d been green and scared, running from room to room, taking care of one patient and knowing I was needed by another patient. Never having a moment to sit and talk with a patient. Never able to give close, individual attention to patients, never feeling in control of my work, that it was all too much for me.

  “I want answers,” the daughter cried. “Why is he like this? Daddy, wake up!” She turned back to me. “Maybe here in the ICU you guys’ll fix things.” She tapped her foot. “God, I need a cigarette.” She brushed away a tear. “This is all because of the terrible health care system we have.”

  I looked down at Mr. Abruzzi lying in the bed. How had he slipped through the cracks? How could so many people have dropped the ball? It was true, his complex care required the juggling of many balls at once, but so many of them had been fumbled! It seemed like all of the gains we’d made in the ICU were lost and we were right back where we started. Would we be able to fix him this time? I went over to the nurse who brought him from the floor who’d just finished her charting. Her name tag said “Melinda.”

  “What’s it like on the floor these days?” I asked casually, an intrepid interrogator.

  “Brutal,” she said in exasperation. “I work casual in Cardiology, but they were short on Mr. Abruzzi’s floor, Gen Surge, so they sent me relieving. I have seven patients, four fresh post-ops, all with multiple IVs and drains. One has a chest tube and three are on oxygen. Only one can get up out of bed by himself…”

  At that moment, Tracy appeared, wheeling over a swivel chair from the nursing station for Melinda. Tracy has always had uncanny intuition. Melinda had given us a detailed and thorough report on Mr. Abruzzi when she’d brought him to the ICU—always a sign of conscientiousness—but Tracy must have sen
sed something was bothering this seemingly confident nurse.

  “No, I can’t stay,” she said when she saw the chair Tracy was offering, but she sat down and burst into tears.

  She won’t last long, I thought. She cares too much. This place will break her.

  “I have to get back.” She stood up. “I’m fine, really.” She wiped her eyes. “It’s just that I’m running full tilt the whole time and everyone is too busy to help me.”

  “When was it noticed that Mr. Abruzzi’s potassium was so low?” Tracy gently inquired. So gently, in fact, that Melinda recognized that she was friend, not foe, and readily explained. “First thing this morning, I saw it was 3.4.”

  “Already on the low side,” Tracy noted. “So, what did you do?”

  “You haven’t worked on the floor in a while, have you?” Melinda said with a wry chuckle. “Most nurses don’t even have time to look at lab values, but I try anyway. When I saw that low potassium, I paged the doctor. An hour later he called me back, but I was in the middle of getting a patient out of bed, so I had to call him back. It wasn’t until the afternoon that I got an order to replace the potassium, but then I noticed he [Mr. Abruzzi] was on a diuretic, so I held that ’cause I knew he’d lose more potassium. I took his blood pressure and noticed it was on the low side. Then I saw his potassium pills on the bedside table. He hadn’t even taken them. Maybe he was confused or forgot, but I had no time to even ask him, and then I noticed his IV wasn’t running very well—I think it had gone interstitial—but by then, another call bell was ringing and I had to run off. I thought, I’ll get to it later but in the meanwhile, I’d better check that potassium again, so I paged the doctor for an order to do blood work, but he was down in the ER with someone who was really sick. Meanwhile, a patient needed a bedpan, a family member was asking me questions, and I didn’t get back to Mr. Abruzzi until he arrested. I was the one who called the Code Blue.”

  I returned to Mr. Abruzzi. His blood pressure was beginning to stabilize with fluids and the inotropes. An hour had passed, so now, with a central line in place, I gave more potassium chloride. I took a 12-lead electrocardiogram (or EKG), scanned it for any obvious problems, then clipped it to the chart for the doctor to review. I listened to his chest and heard crackles in the bases that concerned me. The doctor ordered an x-ray and we reviewed it together. Yes, I thought, here in the ICU, we could rescue Mr. Abruzzi. The problem was we couldn’t keep him safe. We could save Mr. Abruzzi, but what about the nurses who were drowning? What lifeline could we throw them? Their affliction was not hypokalemia or sepsis, but something just as serious: fear, disillusionment—and despair.

  The hospital will never be healthy for patients if it’s not a healthy environment for nurses, where their voices are heard and where they can care for their patients and use the full extent of their knowledge, abilities, and skills. After all, hospitals today have become one big intensive care unit: all patients need intensive caring.

  Conducting an Orchestra

  Sherrill Toldy Collings, RN, BScN

  I AM A NURSE in a busy ICU in a large, urban teaching hospital. My role is called “patient care coordinator;” which combines administration, management, professional development, and clinical leadership. I’ve been working in this ICU for the past 20 years, for many years as a bedside nurse, and now as a PCC. Even after all these years, I still love the excitement and adrenaline rush that critical care provides. Recently, I’ve come to view my role as that of an orchestra conductor: I bring together a variety of instruments, voices, and sounds, and I coordinate them to make beautiful, harmonious music together. Each day, I try to bring order out of chaos. I work with my “musicians,” the nursing and medical staff, along with all the other members of the multidisciplinary team, to coordinate admissions, manage the flow of patients throughout the hospital, plan patient discharges and transfers, ensure that there is adequate staffing for our patients, and communicate with staff, family, and patients. I see my role as enabling the staff to give the best possible care to our patients and their families.

  So many wonderful things have happened at work over the years, but for some reason, I will never forget my worst day in the ICU. Strangely, it was the most challenging, frustrating, yet also the most satisfying and rewarding day of my career.

  It was a Saturday and I was training a new charge nurse that day. The day started out like any other. We sat together in the “fishbowl,” a glassed-in conference room at the center of the ICU, listening to the night shift charge nurse give his morning handover report on each of the 20 patients in the ICU. We were full that day—not one empty bed. All of the patients were very ill, but a few worried us more than the others.

  At that early-morning hour, everything was more or less under control. We got up and went about our daily routines. Within an hour, chaos erupted: A lung transplant patient started to deteriorate. His oxygen saturations were dropping and his blood gases showed a worsening metabolic and respiratory derangement. He was switched from conventional ventilation to high-frequency, jet ventilation. At the same time, he was in and supraventricular tachycardia, or SVT. The patient required electrical shocks, or cardioversion, many times. In fact, we needed to perform that procedure so many times to get the patient back into a normal sinus rhythm that we left the cardiac arrest cart in his room and attached to him, the paddles all ready for use as necessary.

  Just before noon, a nurse came up to me with tears in her eyes. We had a death in the ICU. It was not unexpected, but it was a 45-year-old man with metastatic colon cancer. I started to help the nurse clean and prepare the patient’s body for the morgue, but was called away to help care for another patient. This was a 25-year-old man whose condition was rapidly worsening: He had had a dental abscess. Although he had been started on antibiotics, the infection had tracked into his chest and around his pericardium. I saw the premature ventricular contractions on the cardiac monitor and noted how frequent and differently shaped each one was. The multifocal nature of this arrhythmia informed me that his heart was very unstable and irritable. His blood pressure was dropping rapidly and his oxygen saturations were plummeting. His nurse and I both knew he was pre-arrest. I ran to the ward clerk to have her page the thoracic surgery fellow, who had just been to see this patient on rounds. We paged stat a couple of times with no response. I pleaded with our hospital switchboard operator to break with usual policy to have this doctor paged on the overhead announcement system. (In order to cut down on ambient hospital noise, we try to limit those public announcements.) This time was an emergency. A patient’s life was on the line. After a few minutes, there was still no response from the surgeon, but by now, we were running a full code. The patient had gone into cardiac arrest.

  Our ICU physician called, “Sherrill! Set up the open chest tray! I’ll open his chest myself.” I was scared that this doctor might not have sufficient experience in doing this procedure—yet I knew it was absolutely the necessary thing to do. I was upset, too, that our young patient, a person who had previously been so healthy, was suddenly so critically ill. I knew his family was out in the waiting room, but there was so much chaos in the patient’s room and the situation was still so uncertain that I didn’t know what to tell them. Nonetheless, I went out to explain what was happening and to let them know that we were doing everything we could to save their son’s life. I asked if they wanted to come into the ICU to be present during the arrest. This is a relatively new option that we offer to families, and in some ICUs it is still a controversial policy, but I wanted them to know they could be present if they wished. Knowing the scene going on in the ICU at that very moment would look shocking, and seeing their fragile, vulnerable emotional state, I hoped they would decline to be present for the arrest, and they did.

  I returned to the ICU and went straight to their patient’s room. The doctor had opened the chest and had started internal cardiac massage. The thoracic surgery senior fellow had arrived by then. Next thing we knew, I was helping to rush this ma
n, with his chest wide open, his fibrillating heart exposed, to the operating room for emergency surgery. Off we went, rushing through the halls, three nurses, two doctors—one of whom was manually pumping the patient’s heart, leaving a trail of blood in our wake—and one respiratory therapist who was delivering breaths of oxygen to the now unconscious, heavily sedated patient and protecting his airway. After making sure the patient arrived safely to the OR and seeing the surgery begin, I returned to the ICU.

  The ICU doctor and I went straight to the young man’s parents. The meeting was very difficult and emotional. After we left the family in the quiet room, this very tough surgeon began to sob in the hallway. I took him into my office for privacy and we debriefed with the respiratory therapist, who also was in tears. And then, in the midst of our emotional pain, we heard the strains of a mournful yet uplifting hymn, “It Is Well with My Soul.” A 30-year-old woman who was dying of cancer had the song playing on her portable music player, in a nearby room. Her young husband was with her at her bedside.

  I was so emotional that that soulful music seemed to take me far beyond my immediate reality. The whole day seemed so surreal, so beyond what I could cope with. I felt stretched to my limit, physically, mentally, spiritually. “No,” I said to myself, “it is not well with my soul.” I began to sob and a few of my nurse colleagues, with their uncanny ability to know just when I need them the most, arrived to comfort me.

  Later that day, this woman passed away, her grieving husband by her side. It was the second death of the day. As I was about to help the nurse clean and prepare the dead woman’s body, the OR called with the news that our young man had died on the table. I had to go and deliver this news to his parents. I went down to the OR to help bring the body back so that his parents could spend some time with him in a private room in the ICU, but I met with resistance when I got there. The OR nurse did not want to help me move the patient. She told me to send the parents down to the OR and she’d let them in to see his body. There was no way I was going to ask these grieving parents to come down to the cold, messy operating room to see their son’s dead body, stretched out on the table with his chest cut open, his organs exposed, surrounded by blood-splattered equipment. I leaned in, looked into her eyes, and said, “If I have to move this boy’s body all by myself, I will do that so that his parents can spend time with him in a more comfortable place, surrounded by the staff who cared for their son and who they had gotten to know.” She shrugged her shoulders and went about her work.