Anticipating emergencies.

by rosmary/via Flickr

At the start of every shift after receiving report, I take a moment to consider what emergencies I might anticipate for my particular patient in our PICU. Monitor for excessive bleeding in a liver failure patient. Monitor for an altered neurological status in a patient with a head bleed. I try to envision how I would start CPR in the room if required. I try to be thorough in checking that all my emergency equipment is present and working. I try to keep patient safety at the forefront of my mind and priorities.

I came to work one day and received report about my 9-year-old patient who was post-operative day one from a planned craniofacial surgery. He would remain nasally intubated with eyes sutured shut for a few days until the swelling had reduced, and then would return to the OR to be extubated and to have the eye sutures removed. I’d had patients like him before and felt he would be very easy to keep safe, especially given that per handoff report, he was comfortably sedated and not overly agitated when he did briefly waken with nursing care.

A patient’s question.

As I got to know him through the first couple hours of my shift, I found that he was indeed comfortably sedated though easily awakened, and he responded to my questions appropriately with nodding his head yes or shaking his head no. He didn’t fight his restraints, tubes or the nursing care, but I still got the sense that he seemed anxious.

Soon enough, he began to mouth what appeared to be a question, but it took a few minutes for me to figure out that he was asking when he could go home. I told him it was Friday and that he had had surgery the day before and was doing very well. I explained he would keep the eye sutures and the breathing tube until Monday when he would have them removed in the OR. He nodded his understanding to all the information, and then mouthed a clear “Thank you.” I was proud of my efforts to understand his concerns and gladdened by our ability to communicate.

A patient’s concern.

Towards late afternoon, I went in to reposition him, which caused him to cough a bit. I suctioned him through the breathing tube and stayed at the bedside a moment to make sure he was comfortable and of course, safe. For the first time in my shift, he became very restless and was incredibly animated as he tried to mouth something, pointing to his throat and the breathing tube. He kept trying to mouth words as he pointed to his throat, and I wondered if he was mouthing, “It moved!”

I acknowledged the discomfort of being stuck in a hospital bed with a breathing tube and reassured him that all the things we look for to make sure the breathing tube is in the right place—bilateral lung sounds, good end-tidal reading, and high oxygen levels—were indicating that it still was. He appeared frustrated, and I believed he was trying to express a true concern, but I couldn’t find any clinical reason in the moment to call the physicians or ask for a chest X-ray.

Finally, I reassured him we were keeping a close eye on him, and then gave him a small extra dose of sedation medication to help him calm down. Within minutes, he fell asleep and his heart rate joined his other vital signs within normal range. I went home shortly afterwards, after giving report to the night nurse, and made sure she knew about the incident that prompted me to give my one PRN dose of sedation medication.

What the patient knew.

I learned a couple of days later that, as the night went on into early morning, his breath sounds on the left side became increasingly diminished, which prompted the night nurse to ask the physicians for a stat X-ray. Sure enough, the endotracheal tube had migrated such that it was only in the right mainstem of his lungs. He had been right when he was trying to tell me the tube had moved during our afternoon repositioning and suctioning. It must have continued to migrate towards the right through the night.

Was the patient safe? In many ways, yes. He never actually dropped his oxygen saturation level. He was being closely monitored in an ICU, so as the change was detected, it was addressed and fixed.

But was he safe? I am not sure he himself would say yes. For approximately 12 hours, he was likely just aware enough to know that in his most vulnerable state, something wasn’t quite right but he hadn’t been heard when he tried to express it. His fears had been minimized and the one controlling his ability to stay awake enough to express those fears had given him additional medicine to knock him out. I was the one responsible for causing him to feel unsafe for at least those few minutes of anxiety before I sedated him more, if not also every time he briefly woke over the next 12 hours until the issue was fixed.

Was the patient heard?

While all clinical signs at the time indicated that no additional interventions were necessary, I wonder if I could have reassured him a bit differently, a bit better. Perhaps I could have told him that clinically, he was safe, but that I understood his concern that the tube had moved and that it was something we would be keeping a very close eye on. Perhaps he would have found some additional comfort in knowing that he had simply been heard and that his specific fear was on our minds.

In prioritizing patient safety, I need to know my patient’s pathophysiology and I need to know what I would do if the patient’s condition worsened. But I also need to earn and maintain my patient’s trust by listening respectfully and addressing concerns to the best of my ability. I need to recognize that in the nurse–patient relationship, though I am the medical professional, that does not make me the sole person qualified to speak to the patient’s experience of safety. After my experience with this patient, I now begin every shift with a much different perspective on what it means to uphold and assure patient safety as best as I can.