Recently at work a patient I was receiving report on, was picked up for a CT scan during report.  When I have an elderly patient that is a full code, it does make me nervous at times.  this patient happened to be in his 90's.  Generally the older a patient is, the harder it is to recover from anything, and thus the reason for my increased concern for very old patients that are sick and still full codes.  After report I checked on my other patients and awaited the return of this last patient.  

When he returned he was purple.  One of my coworkers noticed this as he was being wheeled down the hall in his bed.  The aid attempted to get an oxygen reading on the patient while I assessed the situation.  I asked a family member who was present if the patient had looked like this earlier.  Of course he hadn't.  The doctor was paged.  I noticed that 3 liters of oxygen was turned on, but the patient wasn't connected to it.  I connected the patient to the oxygen.  He was conscious, but more confused than he had earlier been.  The lack of blood flow and his atrial fibrillation (a-fib) made getting an oxygen reading and blood pressure very difficult.  I went and tried to find a non-rebreather mask to deliver 100% oxygen.  I found a simple mask.  I applied it and had respiratory paged.  Two doctors were present now.  The respiratory therapist showed up and a non-rebreather mask was applied.

Over the next hour blood tests were ran and the patient was prepared for transfer to the ICU. I reviewed the form we fill out for patients leaving the floor for procedures such as the CT scan this patient had.  We refer to the form as SBARQ.  This is a common acronym we use to give reports.  It stands for Situation, Background, Assessment, Recommendations, Questions.  On this form is an area which asks how much oxygen a patient is on.  It clearly said he was on 3 liters.  At some point somebody did not read the directions.  This occurred either when he was picked up, or at some point while he was gone for his CT scan.  Reading the directions would have helped this patient.  Of course, giving oxygen to a purple patient would have also helped.  His whole situation wasn't due merely to being off of oxygen for a few minutes, but it wasn't made better by that fact either.  When all else fails, read the directions. 

I was working at the Kansas City VA Medical Center, located in Kansas City, Missouri.  I had been floated for the day.  Floating is when a nurse works in a different department than where they are normally assigned to.  This helps fill gaps when one floor is short people and another has extras.  My own grandfather was in an ICU in southeast Idaho.  I was expecting to hear that he passed away any time now.  It was a somewhat normal shift for me, but my grandfather was on my mind frequently.  During the course of my 12-hour shift I did get a phone call confirming my grandfather had passed away.  He was surrounded by many members of our very large family when he was taken off of life support.  I knew it was his time to go, but it's hard losing someone you love.  Our family would be making the trip to Idaho for the funeral.  I returned to my duties and finished out my shift.

I had given report on a couple of my patients and walked around the corner to give report to another nurse when the charge nurse saw me and asked me to get the rapid response cart. A rapid response cart has many of the same things that a code cart does.  Items that we may use in an urgent situation, but not when a patient may need defibrillated (shocked) or intubated (having a breathing tube inserted).  I ran and got the rapid response cart, while another nurse paged the rapid response team.  When I was almost to the room she told me that the patient was coding and sent me for the code cart.  Overhead a code blue was being called throughout the hospital now.  When I returned with the cart 2 people (other than the patient) were in the room.  

One of them was watching, the other was doing chest compressions.  I opened the cart and turned on the oxygen tank, grabbing tubing and and AMBU bag.  An Ambu bag has a mask to place over a patient's nose and mouth, a self-inflating bag, and a port to which oxygen can be connected.  In his haste to be helpful, the person doing chest compressions stopped to help me.  Knowing that minimizing breaks in compressions increases survival rates I began compressions, while he hooked up the oxygen tubing.

I could feel the ribs cracking and rubbing together.  Crepitus is the medical term we use to describe bones rubbing together.  I had heard about ribs cracking during CPR, but had never done CPR before, even with 4 years as an Air Force Medic.  I had imagined the ribs would break at the cartilage joints where they connect to the sternum.  They actually broken along the sides of the chest.  The crepitus decreased as time went on, perhaps because the edges of bone were becoming rounded.  An ICU nurse showed up after about a minute or 2 of CPR.  She began asking who did what, and why hadn't they called a code sooner.  I looked her in the eyes and told her that now wasn't the time for critiquing, it was time for her to do her job.

She looked as me for a second, seemingly in disbelief that a nurse who didn't even work in the ICU dare speak to her that way.  However, she then began running the code as was her job.  Other ICU nurses, residents, and other doctors soon arrived and the room got very full.  Occasionally the dying patient seemed to gasp for air.  It was hard to tell at first if these were real breaths, but as time went on it was apparent that they were agonal gasps.  These are seen in dying people, sometimes even after heart function has ceased.  It was more of a reflex, than a breath.  Gurgles could be heard with compressions.  The patient was intubated, suctioned out and given breaths via the AMBU bag.  The smell of stomach contents was apparent and at times it seemed vomit was being coughed up.  The smell is one I remember to this day.

Every few minutes we would stop compressions briefly and check for a pulse.  Large defibrillator pads were attached to the patient's chest, which allowed us to watch the electrical impulses of the heart on the monitor.  On the monitor we would see very erratic electrical activity.  The rhythm looked far from normal and did not improve with time.  Eventually the rhythm changed to asystole (the flat line you see in the t.v. shows and movies).  After about a half an hour, a doctor finally 'called the code' as we say.  That meant we were stopping our attempts to revive the patient.

I had participated in my first full blown code involving chest compressions.  The patient wasn't mine.  I knew I had done nothing wrong, in fact I was surprised at how well I kept my cool.  Still it was a sad occasion.  The man had no family present and though he was in his 80's, had not been expected to die so rapidly.  I would remember this day, for ironically my own grandfather had passed away too.  The smell seemed to linger on my hands and in my nose for days.  My shoulders and pecs were sore from doing compressions.

When our Labor and Delivery department at the Air Force Academy Hospital closed, we were assigned to work in other hospital areas.  A few of us ended up working on the Medical/Surgical unit, which we referred to as Med-Surg or MSU.  Most things were different working on Med-Surg, but some were the same.  We seemed more accustomed to emergencies, having dealt with resuscitation on a regular basis, and it took a little more to get us worked up.  We had many things to learn about everything that didn't have to do with tiny babies or pregnant ladies.  In any case it can always be easy to underestimate or not believe a patient.  Such was the case of answering a call light one night.

It was several hours into our night shift when I noticed a particular room was repeatedly using the call light.  It wasn't my assigned room, so I asked the assigned medic and nurse what was going on.  I'll call the medic Gertrude.  The RN stated she was too busy and hadn't been in to see the patient.  Gertrude rolled her eyes and said the patient thought he was having a heart attack, but that he was just fine.  I offered to answer the call light and went in to assess the patient.

The patient was a retired service-member.  If my memory serves me correctly, we were told there were about 80,000 retirees in the Colorado Springs area.  In addition to our active-duty personnel and their families, we also cared for retirees and their spouses at our hospital.  This patient fit the profile of many statistical risk factors for heart attack including age, race, and fitness level.

This patient was African-American (a risk category), in his 60s (the older a person is, the more risk of heart attack), and he was not in great physical condition.  In fact he had the body shape known as an 'apple'.  This body shape is one in which a person gains extra weight in the middle.  I asked the gentlemen what he was calling for.  He advised me that he thought he was having a heart attack.  I asked him what it felt like and he began to describe a heart attack: tightness, pressure, shortness of breath, weight on his chest, etc.  I could see he seemed a little short of breath.  He was also a little sweaty.  Either this guy had read the book on heart-attack descriptions or he knew what he was talking about.  I asked if he had ever had a heart attack before and he told me he had.  I asked him how it felt and he told me it felt 'just like this'.  I reassured the man that I would make sure he was taken care of and then placed a non-rebreather mask on him and turned the oxygen up to 15 liters per minute.  

A non-rebreather mask has a bag attached which acts as a reservoir to store oxygen until a person inhales, and it then gives them near 100% oxygen.  I knew that if he was having a heart attack some extra oxygen would buy a little time and maybe a little heart muscle.  In any case it wouldn't hurt him to have some extra oxygen for the time being.  I went out to the desk and reported my findings.

I told Gertrude and the RN that I thought this guy was having a heart attack and that he had one in the past and that it felt like this one does.  While the nurse called the doctor, Gertrude and I obtained a 12-lead EKG and a set of vitals on the patient.  In short order a doctor arrived, blood labs were drawn and the patient was transferred to our Special Care Unit, or ICU.  That was the closest thing we had to and ICU, and it would have to do for now.

Cardiac medications were run through the IV line as they tried to get the patient stable enough for transport to a larger hospital.  The doctor didn't feel like the patient would survive the trip in his current state.  The doctor stayed the night in the SCU, watching over the patient.  After a long night, the patient was finally transferred at around 6am.  

I know he survived the transport and I'm pretty sure we would have heard if he died during that hospital admission.  So I really think the guy made it.  I don't know if he required heart surgery or got a pacemaker or anything else about him.  Sadly we don't often know how a patient fairs down the road.  No matter what department we are in, in a hospital we usually just see a patient long enough to get them well enough to be discharged from our care.  It's pretty rare that we see these patient's again unless they are sick again and are admitted for more medical care.

That night I learned that there are many types of patients and hospital workers.  Their personalities do not always match up in an ideal way.  As providers of medical care it is our responsibility to listen to our patient's concerns and act on them, the patient knows their body better than the rest of us.  Only the patient can really describe pain or discomfort, and only the patient knows for sure when it feels better.