Report from evening shift went a bit like this:

“Ten days post-op for an unresectable tumor. He has been completely fine and almost ready to go home until tonight. At about 17:00 he began having difficulty breathing, abdomen became very distended and firm. He then began having rigors. Temp. 38.5, BP 134/80, Pulse 82, Resps in the 30s. Sats were down into the eighties, now 94% on 5L Nasal Prongs. I placed an NG and had two liters of bright green returns immediately. ECG, Chest X-Ray done, Blood cultures, CBC, electrolytes, troponin sent. He’s Feeling much better after that NG tub. Hopefully it is just an ileus, rather than the alternatives. He just left the unit for an abdominal x-ray. By the way, I filled out an incident report. The lab took two hours to come for stat blood work. Boy did I give them a piece of my mind!”

“OK” I thought, “Perhaps it is just an ileus and he’ll come back to the unit alright. I will settle him to bed and hopefully he can rest comfortably.” I knew it was wishful thinking, but being wishful never hurts. The worst part of the situation was that I had never taken care of this patient. I didn’t know much about him.

About thirty minutes later he came back on a stretcher from his x-ray. One look at him told us he was in trouble. He was gasping for air and he had that distinctive grey colour we all know and love.

He was very weak but he shuffled back to his bed with only two nurses helping. His wife was following closely behind. At this point I was able to take a set of vital signs. Temp 36.5, BP 95/85, Pulse 130, Resps 40, Sats 88%.

“ACK” I’m thinking. This is going to be a busy couple of hours. I ran to the charge nurse and let her know that my patient appeared to be going into shock and we need his doctor ASAP. I grabbed a couple nurses and we got started on extra I.V. access.

By the time the ICU outreach team arrived, we had two liters of N.S. and Pentaspan pouring in. We had started a foley for literally only three drops of returns. ABGs had been drawn, and respiratory had switched him to high flow oxygen.

His blood pressure continued to drop so we placed him in trandelenburg’s. The doctors at this point had looked at his abdominal x-ray and found free air in his abdomen. They decide his surgical site was leaking and bowel contents wer spilling into his peritoneal cavity. They decided, quite easily at this point, that he was in septic shock. I hung flagyl and tazocin.

As N.S. bolus number three started pouring in, the doctors started talking to his wife about his prognosis. His surgery from ten days previous had been for an unresectable tumor on the head of his pancreas that was blocking flow from his duodenum. It had been unresectable, so the surgeons had bypassed the duodenum by performing a gastrojejunostomy—thay had attached the stomach to the jejunum to drain.

What still has me in shock still was that even though it was ten days post-op, the patient and his family were unaware that the tumor was unresectable. They didn’t know that the patient was palliative, they didn’t know he was unsavable. They still had hope that his life was still indefinitely long.

They horrifically had chosen the moment he was on death’s door to tell them this fact and to let them know they should make him a DNR and let him die. They had TEN DAYS to tell him his fate, and had neglected to do so. The surgeons hadn’t had the simple decency to sit down with the family and discuss end-of life issues. Until, of course, he was in the process of dying.

The surgeons, ever hopeful, grabbed his bed and wheeled him to the OR. Perhaps they could find the exact cause. Perhaps they could fix him, clean him out, and send him to the ICU. But, as he told his family, he would probably never leave the ICU.

We use a computerized system, so while he was in the OR I could follow his progress. I saw the moment in the computer when he came out of the OR and was given a DNR status. They were withdrawing all treatment (not care) and letting him go peacefully. They didn’t expect him to live long.

The surgeon came back to update us. His abdomen was indeed filling up. He was incredibly septic. There was nothing they could do. They opened him and closed him almost immediately. The family was already aware.

I remembered the last thing his wife said before he went downstairs to the OR, “If we could just spend one more month together, I would be happy.” That month had turned into minutes.

The decision was made to bring him back to the unit. We set up a private room with chairs and a window with a beautiful view.

When he was brought back, it was obvious that he only had a couple minutes of life left in him. His BP was 60/30 and his Pulse was in the 30s. His resps were just small gasps every ten to fifteen seconds. His breaths almost silent under his chest.

His small gasps stopped and I pressed my stethoscope to his chest. I had never declared time of death before. I couldn’t hear his heart, but I could hear gentle whiffs of air in and out of his lungs.

“It won’t be long now.” I spoke softly. We watched in vigil until we saw his head fall gently to the side and mouth open. I listened to his heart for the requisite one minute. I still could not hear his heart, but there were no more whiffs of air. I told the family he was gone, and left them to say their goodbyes in peace.

In the end, I knew that the team of nurses I was working with did an incredible job. We were, as one nurse stated, “a well-oiled machine.” We anticipated every order the doctors relayed to us, yelling, “we just did that!” with each one.

The only critique of my work was that I struggled in answering many questions of the RTs, Doctors, and ICU nurses regarding the patient. I hadn’t even so much as introduced myself to the patient before this crisis happened. For example, I felt bad when I had to look at my flow sheet in order to tell them his surgery, whether he was on antibiotics, and even his first name! I was truthful though, and when I didn’t know an answer, I said, “I don’t know, but I will find out right away” as I was taught. Sure, it would be nice to know all this information instantly off the top of my head, but I was basically finding out about his situation at the same time they were.

It was a sad night. It was a tough night. But it made me much more confident of my abilities in a crisis. I realized that I really DO know what to do in an emergency situation. More than anything, I learned to trust the nurses who surround me. We are an amazing bunch of people, and I cannot imagine working with anyone else.