August 24, 2006, 11:14 am

A Typical Shift In An ICU, A Devastating Loss for A Family

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Sustained ventricular tachycardia.

Never a good sign.

That night, for Steve’s patient, it was the beginning of the end.

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Steve had never taken care of this particular patient before, although she had been in the intensive care unit for two weeks. He received report:

She had gone into surgery believing she had pancreatic cancer. She came out of surgery to the wonderful news that while a Whipple procedure had been necessary, the mass in her pancreas was benign.

The sigh of relief from her family was audible.

But there was the probability that she had a small heart attack. One doc said yes, one doc said no. They drained a small pericardial effusion. They drained a pleural effusion from the left lung one day and the right lung the next day.

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The patient rarely slept.

She was a bit confused, although she could hold an entire conversation.

She gave her husband a verbal recipe for chocolate mousse and made her sister swear that he put it in the refrigerator. She offered one sister a candy bar, one of many that she “kept” under her sheet. One shift, she kept summoning her nurse to get the “beverage” she ordered.

She wanted her tubes out. She would find the tube and follow it to its source to figure out what it was.She would connive to get her daughters to turn their backs so she could “work” on her abdominal sutures.

A problem solver from the beginning, the patient actually managed to pull out a PICC line! On purpose! In a wide open ICU, in soft wrist restraints while her daughter slept two feet away.

Where there’s a will, there is a way.

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A post-op abdominal CT revealed something unexpected: a clot in the left femoral vein. Heparin and Coumadin were started. The patient began bleeding, source unknown.

Anti-coagulants were stopped.

Six units of blood were given.

Kidney function began to decrease. They couldn’t find the source of bleeding without contrast and contrast was contraindicated because of the patient’s elevated creatinine.

The patients abdomen was becoming distended, she was able to take oral contrast and the repeat CT showed no retroperitoneal bleeding. The surgeons said that she may have a small leak at the surgery site, and an operations was scheduled for 0800 the next day to find, and repair, the leak.

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The patient was intubated as she was now working too hard to breathe, and her continuous pulse rate of 120 had become 145.

Before surgery, it was felt that a filter should be placed to stop the femoral vein clot from dislodging bits and pieces to the patient’s lungs. Yes, they would need to use contrast, but the smallest amount possible. The bigger risk to the patient was the potential for the pulmonary embolism.

Her niece arrived while the filter was being inserted. Up until the patient was placed on a respirator, she had not visited the patient as the ICU was quite strict in allowing visitors other than immediate family.

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The patient developed a pulmonary embolus during the insertion of the filter. Her kidneys shut down.

A Swan-Ganz catheter was placed for fluid management. A Quinton catheter was placed in her left jugular for dialysis.

Except they couldn’t dialyze the patient. Her blood pressure was too low, and she was on Neosynephrine, Levophed, Vasopressin and Dobutamine to keep it up.

“Up” meant 80-90 systolic.

They couldn’t sedate the patient very well, for the very same reason.

They tried a very new type of bedside, continuous dialysis but after six hours the machine broke and the family was told they didn’t have another one and they couldn’t get the rep in until the next day.

The biggest Health Maintainence Organization in the world. At least six or seven hospitals in the Bay Area alone. No one else had the machine.

The niece didn’t get in to see the patient that night, although she kept vigil with the rest of the family in the waiting room all night.

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Multi-organ system failure.

That’s what they called it by the next morning. Said the patient was terminal.

Her husband, a fire-fighter, knew exactly what a full resuscitation meant and made the patient a DNR (do not resuscitate).

Now any family was allowed in. And it took some assertiveness on the part of the family to get that approved. It actually took the form of a doctor’s order.

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Steve took over the patient’s care at 7 pm on that night, around the time the niece returned after sleeping all day.

The niece was sitting at the bedside, holding her aunt’s unresponsive, mottled, vaso-constricted hand and marveling how if she talked, the blood pressure came up.

She kidded her aunt about being her “fifth” drip.

And then came the ventricular tachycardia.

The niece told Steve. Steve made a phone call and about 15 minutes later gave an amp of bicarb. Immediate switch back to Sinus Tachycardia.

The niece marveled that bicarb isn’t usually a first line v-tach drug. Steve looked the niece straight in the eye and said he wasn’t going to place any wager on it being the reason for the conversion.

Twenty minutes later, the patient went back into a ventricular tachycardia and stayed there. Her kids and husband were at the bedside, exhausted and near collapse from no sleep and the impending loss of their wife, mother.

One hour passed, then two hours. Three hours. Four.

Steve stayed around the periphery, available immediately when needed. He worked around up to seven family members at one point. The niece asked if he would set up a Yankauer suction as the patient seemed to be dripping bile from her mouth, and she would be happy to handle any suctioning.

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Eventually the niece was turning off monitor alarms that could not be over-ridden. The patient’s breathing had dropped from 40 to 30 and even with the ventilator it was obvious they were irregular. She watched Steve from the room. He was obviously working behind the scenes. A doctor had come into the unit and Steve spoke with the doctor in hushed tones.

The tachycardia had turned into a sustained ventricular rhythm that would vary in speed. The cuff still marked the occasional BP (the arterial line never functioned), but the cardiac index dropped, slowly, from a high of over 2 to 0.8.

It was pretty obvious that the only thing keeping the patient going were the vasopressors. This could go on for hours….

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The doctor did a neuro check. Pupils fixed. No response to pain. A small, soft-spoken woman, she had actually cried with the family earlier that day when the family was given the terminal diagnosis. She now, very gently, went over, again, what the husband wanted kept up or withdrawn. Antibiotics, nutrition….

The last thing the doctor asked about were pressors. With tears in his eyes, the husband looked at his niece who said, “it’s the only reason she’s still here”.

The patient’s husband asked to stop the vasopressors. The son was enroute back to the hosptial, having left just an hour before. Could we wait until he came back?

Of course.

But the patient had other ideas.

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The minute the decision had been made to withdraw the pressors, the patient, after sustaining a ventricular rhythm for over four hours, slowed her rate to 35 and went into a PEA. Any spontaneous respirations ceased.

It was almost as if she was given permission to leave, as her husband acknowledged his acceptance of the situation.

The ventilator and drips were maintained for an additional 10 minutes, allowing the son to arrive. They were then stopped.

The grieving family gathered the cards, hand-drawn pictures and photos and left the hospital.

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The patient was my aunt and we lost her on August 23, 2006 at 0300.

She was 15 when I was born and my first two years were spent in the same house she lived in, Mom being only 17 and Dad in the Navy.

She called me Pee-Pot, a moniker which I, thankfully, outgrew.

She leaves behind a husband, a brother, a sister, three children, eight grandchildren, two foster-grandchildren, seven nieces and nephews and her 90-year-old father, my last remaining grandparent.

She is the third relative in six years that I’ve lost who has been under the age of 65. My dad, my uncle and now my aunt.

The only thing that makes this loss even remotely tolerable is that she is finally reunited with her mother, lost to cancer when she was nine-years-old. She always told me she had never stopped mourning the death of her mother.

They have a lot of catching up to do.

As for me, I’m just numb.

And the irony of it all is that she didn’t have cancer.

God certainly has his own timing. I pray that one day I’ll understand it.

34 Comments


  • Dawn

    August 24, 2006 at 2:15 pm

    Kim…so sorry to read of your loss of your aunt. My heart goes out to you and the family.



  • Susan

    August 24, 2006 at 3:33 pm

    Kim,

    You and your family are in my prayers. This past June, my own aunt died after a year in and out of the ICU. She remained strong-willed to the last, too.

    Your perception that she died after being “given permission” sounds right; many people do need or wait for that permission. If you don’t know the book FINAL GIFTS, written by two hospice nurses, it’s a fascinating (and ultimately hopeful) look at just how much control people have over their own dying processes.

    As for God’s timing: yep, it really stinks sometimes, doesn’t it? We’re all going to have a LOT of questions when we get there. (“WHAT were you THINKING? WE could do a better job than that!”)

    May you and everyone else who loved her find hope and comfort in your grief.

    Blessings to you,
    Susan

    P.S. I have a much less cosmic question about ICU visitor regs. What if someone doesn’t have biological family? Would friends not to be allowed to visit?



  • Judy

    August 24, 2006 at 5:28 pm

    I am very sorry for your loss. God’s timing certainly isn’t ours, but some day we will all be given the gift of understanding it.



  • Nickie

    August 24, 2006 at 6:43 pm

    Oh, Kim, I’m so sorry. And you managed to put this, and “change of shift” together. You and your family are in my prayers.



  • Thumper

    August 24, 2006 at 7:10 pm

    Having just lost my most awesome father in law, I am feeling your pain quite a bit. We buried him yesterday…one of the things the pastor said at the funeral was that God has his own way and his own time, and it’s not up to us to understand it but to trust it.

    We kind of have to. Otherwise it hurts too much.

    I am so, so, sorry…There’s not a thing anyone can say that will make it hurt less, but you do have our well wishes and prayers.



  • Prisca

    August 24, 2006 at 8:21 pm

    I am so sorry for you loss. May God shine His face upon you during this time…

    (((HUGS))) Prisca



  • Kelly

    August 24, 2006 at 9:59 pm

    Ah, Kim…..

    You were an incredible niece to a wonderful aunt….

    Hold THAT close….

    Love ya….



  • FRECTIS

    August 24, 2006 at 10:15 pm

    I’m so sad for you. Bless her and all of you.



  • Kj

    August 24, 2006 at 10:41 pm

    God Bless.
    You and your family are in my prayers



  • Janet

    August 24, 2006 at 10:45 pm

    So sorry for your loss, Kim.
    You and your family are in my prayers.



  • OneKewlRN

    August 24, 2006 at 11:36 pm

    Kim,
    My heart and prayers go out to you and your family.
    Take care of yourself and each other.



  • Doris

    August 25, 2006 at 2:18 am

    I’m sorry for your loss. Cyber hugs to you and your family.



  • Chele

    August 25, 2006 at 3:48 am

    Kim, I’m so sorry for your loss. My prayers are with you and your family.



  • kim

    August 25, 2006 at 4:03 am

    Kim,
    Sorry for your loss. You writing, I hope, is cathartic. It helps both you and us readers with our own losses as well….peace.



  • Intelinurse2b

    August 25, 2006 at 5:44 am

    Kim-
    I am so sorry for the pain you must be feeling. Your family seems so supportive. Such a blessing you wil assuredly rely on as you grieve.
    I will remember you in my prayers.



  • Bob

    August 25, 2006 at 6:17 am

    It was at “The niece told Steve.” that I knew where this was going. My condolences.



  • Sharon

    August 25, 2006 at 7:05 am

    Oh Kim. My heart aches for you… I was at the same place Bob was ( “The niece told Steve…”) when I knew this was about you…. What a terrible thing to happen and what a lovely memorial to your aunt you wrote at the end. May her memory be a blessing to you and your family. May you know no more sorrows.
    Sharon



  • Wendy, S.N.

    August 25, 2006 at 7:49 am

    Kim,

    I am so sorry for your loss. You are in my thoughts.

    W.



  • Sid Schwab

    August 25, 2006 at 8:32 am

    It’s an excellent example of how providing health care is really a (hopefully) sophisticated game of odds-playing. Every decision that’s made has a potential downside, and whatever happens is 100%, no matter what the statistics say.

    Diagnosing a mass in the pancreatic head is a dramatic example of the imperfections with which we deal, and the possible consequences….



  • DisappearingJohn

    August 25, 2006 at 9:53 am

    Kim,

    Add me as well to the list of people who have you and your family in my thoughts and prayers…

    John



  • That Girl

    August 25, 2006 at 11:41 am

    Im so sorry! Big hugs!!!



  • marachne

    August 25, 2006 at 12:03 pm

    My thoughts are with you too — it’s such a strange place to be in isn’t it, when the personal and professional worlds get all jumbled together. Sometimes taking on those physical tasks makes it easier, or at least makes the family around you feel better, since they know one of their own is there too.

    I’m sorry if I’m repeating myself, but it’s also been my mantra the last few days as I’ve been dealing with several families trying to come to terms with unexpected end-stage situations, who say “I know you can’t really tell me, but how much longer?” Death is like that other big transistion, birth: we, the bystanders/witnesses, have no control over how, or when–it is between that individual’s spirit and Spirit. We can only witness, support, and clear the path with our love.



  • Karen

    August 25, 2006 at 5:09 pm

    Oh, Kim. :: GREAT BIG HUG ::

    I am so sorry to hear about your aunt’s death. My thoughts are with you and your family during this difficult time.



  • Mother Jones RN

    August 25, 2006 at 6:30 pm

    Kim:

    I’m very sorry for loss. My thoughts are with you.



  • Mama Mia

    August 25, 2006 at 7:40 pm

    Kim, my thoughts are with you and your family as you grieve this loss. Despite everything you posted I cannot help but think that your presence made the whole event easier for your other family members. I hope you have someone to support you as you have supported everyone else…



  • Melissa

    August 25, 2006 at 10:04 pm

    I am so sorry for your loss. You and your family will be in my prayers.



  • PaedsRN

    August 26, 2006 at 1:28 am

    ICU sucks just a tiny bit, doesn’t it?

    Sorry hon. Take time for yourself.



  • Mary Lu

    August 26, 2006 at 2:40 am

    Kim, Dr. Doug and my thoughts are with you and your family. When we read your post we couldn’t help going back about 18 months ago. We were in your position, and the patient was Dr. Doug’s Father. Of all the gifts we give to our family, it is when we give back to our family in caring for them at the time of their passing that is the greatest gift of all. We give them our love and honor and allow them the dignity to pass in peace. It is also the hardest job we ever will do. You did the right thing for her, out of love and admiration– take time to give yourself some time to understand that and be at peace.



  • Ron Hudson

    August 26, 2006 at 11:27 am

    This story was eerily like what my mom went through from December to April of this year. We managed to get her to the proper care just in time for each event that came along and she recovered at 81 years of age. Although some had given up on her, I knew that there is always room for hope and loss of hope is loss of life. I am so sorry about your aunt but I also understand the consolation of knowing that someone has reunited with loved ones past.



  • NPs Save Lives

    August 26, 2006 at 7:44 pm

    Sorry to hear about your Aunt. I’m sure that you will always remember the good things. The bad ones will eventually fade. You are in my thoughts.



  • Dawn

    August 26, 2006 at 8:43 pm

    I’m so sorry for your loss Kim. My thoughts and prayers are with you and your family.
    Dawn



  • AmandaM

    August 26, 2006 at 10:07 pm

    Oh Kim – I’m so sorry to hear about your aunt’s death. My aunt died in april, unexpectedly, and it was hard. Hugs to you and your family.



  • ltaylor

    August 28, 2006 at 1:11 pm

    Kim, I am so sorry to hear about the loss your family has experienced. I wish you all peace. God Bless, L



  • CardioNP

    August 28, 2006 at 9:46 pm

    May your blogging help you in your time of loss.

    ****
    I can’t believe there are still ICUs that screen for immediate family members in this day and age. As long as there are only 2 people in the room at a time, what does it matter what the relationship is?

    It has been years since I worked in the unit, but I never cared how the visitors were related, just made sure that the visitors didn’t interfere with the pt care/activity in the ICU. If it was a dying pt, then curtains were drawn and rules were bent.
    These silly “immediate family only” rules always irk me.


About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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