Divergence...

There is a me me.  And then there is a you me, a them me, and so on, and so on.

Only I know what I am truly thinking and feeling; as for another to know, I must express or communicate a message, that is received and interpreted correctly.

This is one of the hardest things, as an experienced Nurse, that I have struggled with.  Don't get me wrong.  I will fight, argue, stand toe-to-toe, and push myself to physical exhaustion and eventual collapse... when it is warranted, in order to save a life.

I will also do the same, when it is not... and it is best to just let go.

As any student of history knows, battles often turn.  It is a good commander, that realizes that defeat is inevitable, and to spare as many as possible... retreat is often the most prudent action.



So here is my recent experience...

A peer was providing 1:1 care for a critical patient.  I was not involved directly, only providing cross-coverage to their other patients with yet another peer.  After a few hours, they came to me and asked  to help them troubleshoot the Art-Line (arterial line, placed to provide real-time, instant, constant measurement of blood pressure).  It seems that although there was a wave form, there was no numerical reading.

I went through the checklist... catheter in place, not kinked, tubing attached, all stop cocks open, transducer at heart level, tubing not kinked, pressure bag inflated, positive flow, a re-zeroing completed...

Still a wave form, correlated to the ECG, yet no numerical display.  A closer look at the wave form showed a systolic pressure below 50... A check of the femoral pulse, it was intermittent, barely felt even then.

Now into battle mode, as I only had a general knowledge of the problem...

Tank full?  Yes, over 6 liters of IV fluids so far.  Pressors?  Levophed and Vasopresin.  My decision and instructions: bump up the Levophed, call the Admit Team (they need to be at bedside!), and run in another liter of IV fluid until they get here.  What is the history?  ... a terminal cancer, end stage, probable metastases, failed G-tube placement, probable mesenteric infarction...

I changed my decision and instructions.  The short time they were in place and being followed, and before the Admit Team arrived, we regained a blood pressure of 50/32... a MAP of 38, which was obviously lower for the last five to six minutes as it wasn't even registering...  I then suggested we stop the IV fluids, lower the Levophed back, and wait for the Admit Team to arrive.  I looked at my peer, and saw that they knew, they just wanted someone else to make the decision.  So I said to them, "You did a good job, everything we could have done, was done."

One could see and feel the weight lift off of everyone in the room... which were only Nurses, ED Paramedics, and ED Techs.

Then the Admit Team arrived.

As they started to assess and shout out orders, no one moved, no one did anything.  My peers all just looked at me, some of them even left the room.

When the Senior Physician at bedside was finally able to understand that I was the defacto 'Resuscitation Captain,' they turned to me and asked for a synopsis, a report of the events that had occurred.  My peer, the Primary Nurse for this patient was near tears.  I looked directly at them and said, "Thank you for your help, go take a minute."  They left the room.

My synopsis was brief and to the point.  I also offered my suggestion that 6+ minutes of a MAP less than 38, is not conducive to a long term survival.  A MAP of 60 is necessary to adequately perfuse the end-organs... heart, brain, kidneys, etc.  This patient was now at a minimum brain dead, multi-system organ failure was impending.

They insisted on starting an Epinephrine drip and a few other things, that I ended up handling and assisted with.  All the time, I kept mentioning that, pardon the reference, "We are flogging a dead horse.  There is a time to just stop."

The patient made it to the ICU.  They died a few hours later.