Friday, November 11, 2005

The Yearly Visitor

I often find myself with writer's block, especially when I stop to think that people are actually reading what I write. I have to remind myself that blogging is not a performance art, it is a (hopefully) creative outlet for emotions, opinions and commentary.

I often find myself blocked from adressing a specific topic because I'm only minimally anonymous on this blog, if at all. I worry about HIPPA regulations and patient confidentiality.
Sometimes it's easy to change the sex, age and chief complaint of a patient and not affect the story or its outcome. But what happens when you can't do that; when the details ARE the story? How can I describe what was the most tragic, gut-wrenching shift of my career with a patient I can't forget..... because she returns every Fall?

I have decided to tell this story in the form of a letter to my patient, covering up the details to the best of my ability. Who knows, I may just delete the whole thing when I'm done, but it is Fall again, and she does come around.

"Dear Melissa,

It's been many, many years since our meeting in the emergency department late that holiday night. The evening you told your mom that you would join the family over at Grandpa's as soon as your headache improved. You didn't show, and your mom came home later to find you unresponsive on the den couch. She called 911. We met around midnight.

The paramedics gave you some medication en route and you responded to one of those medicatons. By the time you arrived, to have called you agitated would have been an understatement. This was a different kind of agitation. Your eyes were open but they did not see. You thrashed and writhed but not because of any particular stimuli. You screamed a scream we could not understand but could not seem to hear when we tried to speak. You looked right through us. I'd never seen that stare before. I will never forget it.

We noticed that you were oozing blood from a nasal airway attempt en route. And you were dripping from both IV attempts the medics made. The entire department and half the hosptial met the ambulance that brought you to us and many things were occuring simulaneously. The nurses inserted a foley that returned red urine. Every place you hit while thrashing turned ecchymotic. You leaked around the IV insertion sites we put in. Somehow the ED doc managed to do an ENT evaluation. Blood behind both tympanic membranes.

Disseminated Intravascular Coagulation (DIC). All I knew at the time was that it was 60% fatal. The lab confirmed it. The question was why? The specialists started arriving. Internal Medicine. Hematology. Respiratory. An ABG was done; pressure was held. You didn't stop bleeding. Blood cultures done. More bleeding. You continued to thrash against the barriers we had put up. We tried sedating you but nothing worked; your respirations remained sixty and deep for hours.

Your mother stayed in the room with you after the majority of the procedures had been done.
I stayed calm and conversant even though I knew you were critically sick. I told her to try and talk to you because you could probably hear her. I told her you were the same age as my daughter. I learned you were taking college classes and happy with a part-time-job. I learned you had a recent break-up but seemed to be getting over it. I learned you had sisters. Your mom wondered if she should have your father called and get your sisters to the hospital.

I said yes.

The rest of the hours are a blur after so many years. No time to chart so I kept grabbing paper towels and putting my notes on them. By now, the other two nurses had to go back to taking care of the other patients in the totally full ER. You were nowhere near stable enough to transfer to ICU, although we had had the room for awhile now. I ran with IVs and medications and clotting factors and FFP and blood and reinforcing dressings and a million other things that needed to be done.

Then it got very quiet. I looked over to find that you had laid back down on the pillow. You became unresponsive except to painful stimuli. It happened that fast. I told the ER doctor that your breathing had suddenly dropped to 20 per minute and that you were no longer thrashing.
He intubated you without any response except a ET tube full of blood. An NG tube also was passed. No response. More blood.

The family came back in, this time it was your dad and your sisters. I explained what each tube was for, what we were waiting for. Your dad asked if this was bad.

I said yes. It was very serious.

More hours flew as I worked with you with your family at the bedside. By now we knew that your tox screen showed the presence of some pain medications and that your acetaminophen level was normal. Mom remembered some complaints of an upset stomach during the week.
I wish I could remember all the details and technicalities that went into my non-stop 7 hours of caring for you, but my memory is fading where the technical stuff is concerned. It has never faded where you are concerned.

At 0700, you were stable enough to go for a CT scan of your head. It looked like a pristine scan. No bleed. No swelling. Your mom joked about telling you she saw your brain. After the scan we went up to ICU where the new nurses took over and settled you into their unit. I heard them say to start Dopamine. I said good-bye to your parents and to you and returned to the ER.

I had seven-and-one-half hours of nursing care to account for when I sat down with a cup of coffee to do your chart. And I'm obsessive with my charting so it was a little after 0930 when I went back up to the ICU to give them the missing nurse's notes. I walked in just in time to see your agonal rhythm on the monitor. My heart sank. I was told they had decided to take you off the ventilator.

You were no longer breathing. I saw your heart stop beating. Your father fell into my arms, sobbing. Your mother cried and hugged me and thanked me. I touched your hand and said good-bye and held myself together as best I could.

Until I got to the ER, where I made it into the bathroom, shut the door. The sobs came. Hard. I leaned up against the cold tile wall in a fetal position sobbing so hard I ached. Half-an-hour I did that. I pulled myself together enough to get in the car where it started again. All I could say was "Oh God, Melissa, I'm so sorry" over and over. I couldn't come back to work the next night. Or the next night.

They said you died of an overdose of acetaminophen. Only you know the whole story.

I'm so sorry Melissa. I'm so sorry we couldn't save you. I will always wonder if there was something more I could have done. Something I missed. Something that would have stopped that cascade of death that overpowered us all that night. Sometimes, as we tug-of-war with God over a patient he lets us win. He won that night and Heaven is richer for it. We are the poorer.

I think of you often, but mostly this time of year. I wonder how your family is doing, I think of how old you would be now. And every time my family bows their head to say grace over Thanksgiving dinner, I say a prayer for you and your family. Put in a good word for us, too, okay?

Thanks for visiting me again this year, Melissa.
See you next November.

Your Nurse,
Kim



20 Comments:

At 11/12/2005 04:48:00 AM, Anonymous Jenn said...

That made me cry. I have a patient like that too.

 
At 11/12/2005 07:30:00 AM, Blogger kenju said...

I am typing with tears in my eyes. I wonder why she took an overdose of acetominophen. Too bad that happened. Her poor parents.

 
At 11/12/2005 10:28:00 AM, Blogger ICU 101 said...

you write so beautifully, Kim... that story is so heartbreaking, i can't imagine how you must feel, even all these years later... you did a fantastic job caring for her...

 
At 11/12/2005 10:38:00 AM, Blogger Dr. Deborah Serani said...

You have a great blog here, and your posts are thoughtful, well crafted and ALWAYS of interest. This is a most sensitive piece, and one that pulled at my heart too.

~Deb

 
At 11/12/2005 11:20:00 AM, Blogger I am a Milliner's Dream, a woman of many "hats"... said...

What lovely support for the client and her family...

...and now as a nursing student I find myself wondering--her acetaminophen levels were normal, but they decided she died of a Tylenol overdose? Why was she bleeding out everywhere--I'd think aspirin, not Tylenol.

Fascinating, sad, and I know I'm in for this kind of thing. I love to read and learn from you, Kim.

Hh

 
At 11/12/2005 01:01:00 PM, Blogger Kim said...

An acetaminophen overdose destroys the liver. We never knew if it was intentional. Sometimes people take more than normal because they think Tylenol is safe. The trouble is, you may not see symptoms for up to 24 hours and even then it's like nausea and slight abdominal pain. If you don't realize you have taken an overdose or you don't tell anyone that you took an overdose, within a week your liver is gone. That's the thing with Tylenol ODs whether intentional or not. You take them, you don't tell anyone thinking, oh I'm fine and then you are dead a week later. I've seen it twice in my career. That's why all tox screens will cover aspirin and acetaminophen.

 
At 11/12/2005 01:36:00 PM, Blogger Orikinla Osinachi. said...

May God comfort the bereaved.

 
At 11/12/2005 05:19:00 PM, Blogger ChiaLing81 said...

What a tragically beautiful and touching piece. Your post made me cry. You are a powerful writer, Kim. Thank you for sharing with us.

 
At 11/12/2005 07:32:00 PM, Blogger Heather said...

Some patients leave a permanent imprint on our hearts. The day I stop crying over the senseless tragedies will be the day I know I need to retire from nursing.

Thank you for a beauriful letter to Melissa and a beautiful insight into your heart, Kim.

 
At 11/13/2005 09:35:00 AM, Blogger The Platypus said...

DIC is like a race that you can't win but you have to keep running. I didn't know that acetaminophen could trigger it, but I always marvel at people who make suicidal gestures with medicines that won't usually kill them but which will damage organ systems to the point of permanent disability. We had one last night, didn't know what she took but I guess it was more effective than most because she wound up intubated as she became more obtunded at the end of the night.

I wouldn't worry about HIPPA unless her name was really Melissa and you sent a link to her family.

 
At 11/13/2005 11:44:00 AM, Blogger Chris Rangel said...

A great many things can trigger DIC (not just infection). Acetaminophen's (Tylenol) main effects are on the liver causing massive necrosis and ultimately liver failure. Since the liver is responsible for making several proteins that are critical to clotting this could also be the cause of the diffuse bleeding.

It can actually take several days for the full effects of an acetaminophen OD to result in liver failure and by that time the levels may be "normal".

It is not an easy way to die. It is tragic that many suicides by Tylenol OD are actually accidental and made by people who really don't realize that Tylenol can kill (>20gms in < 12 hours).

 
At 11/13/2005 01:38:00 PM, Blogger Gypsybobocowgirl said...

Beautiful post that all of us nurses out there can relate to. I was struck by your referral to fighting God for the patient...that is how I felt many, many times working in the ICU. Sometimes I won, sometimes I lost, but somehow, I always knew that God would ultimately make the decision.

 
At 11/14/2005 05:38:00 AM, Blogger Nurse Practitioners Save Lives said...

How sad for nurses and family to have to deal with these tragic circumstances. People have always had a problem with "well, if one pill works, two should be better". It's really tragic that most overdoses are not done on purpose. The holidays make it worse when we lose someone close at those times. Thank you for the post. Screw HIPAA.. fight for free speech with names changed to protect the innocent.

 
At 11/14/2005 06:50:00 PM, Anonymous Susan said...

That was a beautifully told recount of your sad night. You are a wonderful person.

 
At 11/15/2005 12:25:00 AM, Blogger PaedsRN said...

Thanks for this, Kim.

It's interesting because... I suspect, like Jenn, we all have patients like this, but mine don't call to see me every year. They rest in my hind brain somewhere, between the bit that stops me from making drug errors and the bit that allows me to make good decisions (some of the time.) I often feel them there, adding footnotes and editorials to my practice, inserting a memory where it'll do the most good. Sending my hands to the right place at the right time. Keeping me quiet when all that's needed is stillness.

Experience. Isn't it just a collective noun for all the patients we wish we could have saved?

 
At 11/15/2005 12:52:00 PM, Anonymous ELiles said...

I too arrived at an ER in a state of near death from a heart attack caused by having smoked for 45 years. My doctor also worked frantically to save me but prepared my husband for the worst. That night God let the doctor win and here I am nearly 15 years later still in awe of what happened to me as well as what could have happened. I'm so thankful there was a doctor there who would not give up. I write to him every year on the anniversary and tell him how I'm doing and how much I appreciate what he did.

 
At 11/16/2005 01:47:00 PM, Anonymous pixelrn said...

I love the idea of being "visited." It brings me comfort in a strange way. I like to imagine deceased ICU patients giving comfort to the ones who are currently dying.

 
At 11/16/2005 06:07:00 PM, Anonymous Anonymous said...

Just today I reminded a patient again that a med she's taking (Vicodin) also has Tylenol & not to take the 2 together. She reminded me that I'd told her that before. But your post made me glad I repeated myself again today. Thanks.

V

 
At 11/16/2005 10:51:00 PM, Anonymous Anonymous said...

I read a story about a man who was addicted to Vicodin. He took it in prolific doses. Not only did he not know that he was killing himself with the acetaminophen content, he didn't know it contained a narcotic.

That's just stupid.

 
At 11/20/2005 09:21:00 PM, Anonymous Tatiana said...

Beautifully written. I had an acetaminophen OD the other day.

 

Post a Comment

Links to this post:

Create a Link

<< Home

Creative Commons License
This work is licensed under a Creative Commons Attribution-NoDerivs 2.5 License.