“Patient in room 709 didn’t sleep all night and thinks his call light is to get the cops to come and arrest us,” said the night shift nurse as she packed her things.
How can nursing be so predictable and unpredictable at the same time? As soon as I walked into his room and tried to introduce myself, he exclaimed, “Oh great, another woman; if they really think they can keep me here, they should at least bring a man to do the job!”
“Well, good morning to you too,” I thought and proceeded to kindly help him understand what was going on. “Good morning, Mr. Brown, I am your nurse, and you are in the ICU. You’ve been awake all night, and breakfast will come soon.”
He had surgery on his large intestine to remove an obstruction, and they happened to find a large cancerous tumor as well. They closed him up, but only partially; his dermis and subcutaneous fat were still open and packed with wet-to-dry gauze. The unfortunate thing was every time the nurses tried to remind him of why he was in the hospital (which he forgets about every 20 minutes), they had to deliver the sad news of the cancer and help him through the grief. Over and over.
Since the surgery, he had been so upset and delirious that he refused to eat or sleep. The doctor had him on a full-liquid diet, but of course, his family would bring him his favorite food- fried chicken. One of the worst possible things someone could eat after having part of their intestines removed.
We had educated the family, “Ya know, hey, this really can’t be given to him; the doctor has specific orders for his diet, his body can’t process such rough food, and giving it to him could cause unneeded complications.” So they brought a cheeseburger and chicken nuggets instead, and before we knew he had even eaten it, he was vomiting everywhere.
We also had to explain to the family that the confusion had been attributed to hospital delirium and that, hopefully, it would clear up quickly.
As I helped him take his morning meds, popping each pill into the medicine cup, he started to get out of bed to go to the bathroom. The night shift nurse had told me he still wasn’t strong enough on his feet and couldn’t get up without three people. Everyone knows the morning is the worst time to need help, so I grabbed the urinal and explained it to him. He started arguing and trying to get to the edge of the bed. As I struggled to stop him and tried to convince him he really didn’t want to try standing up without the proper help, the doctor poked her head in and said, “Hey nurse, I put in a bunch of orders on your patient in 708, we need to go to CT before rounds and start rectal lactulose, I put in the order for the rectal tube.”
My other patient in room 708 was sedated on the ventilator with a strong dose of Propofol and just a hint of Fentanyl. A few days ago, he had been intubated in the field with altered mental status from encephalitis and was found to have a positive urine drug screen. I went into his room, gave him a quick morning assessment, and checked my drips and restraints, tying them closer to the foot of the bed like I always do. After ensuring he wasn’t asynchronous with the ventilator and his vitals were stable, I left to help Mr. Brown, who was calling for the umpteenth time.
Before I saw his family had arrived, I could already smell the greasy french fries they had brought him. I went in to hang his antibiotics and made sure he didn’t need to use the bathroom, even though I really didn’t want to hash out another argument with him. I asked the family if I could put the food in the fridge for later (because I don’t think they’re going to stop bringing it at this point), and as I was walking out, I saw on his bedside table a bunch of lumped-up dirty gauze. I audibly said, “Dear God,” and dropped the fast food to check his abdominal wound. Yep, he had removed the dressing himself, and it was now bleeding and exposed to whatever bacteria he had on his hands.
I looked him in the eyes defeatedly, without even knowing what to say. I turned to the family and explained that he must have taken it out while neither of us was in the room. Just as I was finishing repacking the wound, the surgeon walked in. He starts talking with the family, goes to examine the wound, and of course, undresses what I just put on. I told him what happened with the wound packing, and he asked me to try an abdominal binder to prevent it from happening again. Not having much faith that it would work, I couldn’t think of a better idea and was happy to leave the room for a second.
Before returning to Mr. Brown’s room, I wanted to give a few meds to the patient in 708 and see if I could get that rectal tube in. As I walked in, I looked up from my full hands to see he was starting to move around. I dropped my meds somewhere without caring if they fell on the floor and immediately went to his bedside to make sure his restraints were still tight, the IVs looked good, and the sedation was running. I gave him a little bolus of Fentanyl and increased his Propofol while softly placing my arm on his chest. I stood there for a few seconds with my eyes locked on him before he brought his legs up. “Don’t do it, don’t kick me in the head!” I pleaded as I used my other arm to gently direct them back down, but he quickly communicated he wasn’t a frail little grandma. “Gentle” wasn’t going to work for anyone here.
By this point, I was up on the bed, had both my hands on his shoulders, my knee pinning down one of his legs, and it only fueled his fire. Not usually do I have to yell for help- well, okay, sometimes I yell for help. With desperation in my voice and the adrenaline building, I shouted, “Help! Anybody! Help me!” while struggling to keep this bull in his chute. If I remember correctly, I believe the administrator was standing near the door and just stood there, clipboard in hand, eyes wide.
My friend sprang into the room and called a staff emergency to round up any free hands. We maxed out his Propofol drip right before he contorted his body to sit straight up and busted both of his restraints, launching his hands up to his mouth. I quickly clamped down on his wrists, his fingers only centimeters away from his tube, pulling away with all my might as he shook me around like a mouse biting on the end of someone’s finger. Somehow his tube stayed in his throat but disconnected from the vent, which caused him to lose just enough steam for us to push a few milligrams of Versed. At the same time, the respiratory therapist reconnected him to the ventilator. Just a little bit late, a beefy male nurse (yes, the type of nurse Mr. Brown said we would need) came in to muscle him back down to his pillow the rest of the way.
After replacing the restraints, starting a Versed drip, and getting him calm enough for a CT (that rectal tube got bumped down pretty far on my chore list), I organized everything for the trip to the radiology department. Still sweaty and jarred, I walked down the hall to grab a few safety medications for travel; Mr. Brown’s son jumped out of the room with tears in his eyes. I looked at him confusedly and leaned over to glance at Mr. Brown, who seemed fine. Still puzzled, I looked back at the son, who angrily exclaimed, “Our dad mentioned yesterday the doctor told him he only had 72 hours to live; why didn’t anybody tell us this!?” My eyes got big, and I said, “What?! No, no, no, that’s not true at all!” I squeezed my eyes shut and shook my head. “I’m so sorry he told you that, as you know, he has been struggling with hospital delirium, and that most certainly is not true. If it was, we would have told you.” He looked exhausted as his tears started to trickle down his cheeks.
Behind me, the respiratory therapist shouted, “Hey, we need to go now!” I told the family member we would have more time to talk later but that he shouldn’t worry. I tossed the safety medications at the foot of the bed with the monitor and started to push the bed out of the patient’s room. We were almost into the elevator when the charge nurse came around the corner and nervously called out, “Hey! Before you go, I just need to tell you that you’ll have to take on a third patient when you get back!” and the elevator doors closed. The respiratory therapist looked at me to see if I was going to crumble, and he said with a smile, “Could’ve seen that coming a mile away.”