1. Lutz, Heidi MSN, RN, CCRN


As a new RN, treating this patient taught me many lessons.


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Marvin Smith was unforgettable. (Identifying details and his name have been changed.) He was one of the first patients I cared for as a new RN.


I was working the 12-hour night shift. Even as a novice, I could tell that Marvin was not well. He had had a coronary artery bypass graft three days earlier and was to be discharged the next morning. I knew that a patient preparing for discharge should not suddenly need more oxygen- Marvin was on a 60% face mask, but he had been on room air earlier that day. Marvin's abdomen was also firm and distended, and he complained of abdominal tenderness with palpation.


I felt ill at ease. I did not know what was wrong with Marvin, but I decided to notify the on-call physician, who, according to the ICU flow sheet, had not been alerted. I thought, Surely the physician must know [horizontal ellipsis] but what if he doesn't? I struggled with the decision to call; many of the nurses did not call the physician at home unless it was urgent. Was this urgent? To support my assessment of Marvin's condition, I collected every possible objective marker: vital signs, oxygen saturation, recent lab values, and neurologic status, which had begun to deteriorate after I arrived. He was increasingly lethargic.


I made the call. The physician hadn't been informed about Marvin's changing status, and he ordered further assessments. Marvin now needed a 100% nonrebreather mask to maintain oxygenation. He was barely coherent, and his color grew poorer. He was clammy, mottled, and cool to the touch.


A chest X-ray was taken. A laboratory technician who came to draw blood couldn't get any-I realized later that Marvin's blood vessels had severely constricted. I called the physician, feeling more confident, and he said he would come in immediately. I updated Marvin's visiting family and asked them to step out of his room.


The physician arrived and ordered a femoral line placed. During this procedure, Marvin stopped breathing. He was coding, something I hadn't dealt with in nursing school and had always feared.


Marvin was stabilized and placed on a ventilator. The physician asked me to speak to the family while he arranged for an exploratory laparotomy. I thought, I can't talk to them; what do I say? But it had to be done. I told them that because of Marvin's increased difficulty with breathing, he needed to have the breathing tube again. Their knowledge of medicine was limited, so I used very simple terminology-something I was inexperienced with. The physician joined me and told the family that Marvin had a serious infection from a preexisting stomach ulcer-neither he nor his family had thought to report to his physicians that he had chronic heartburn. The stress of surgery had caused the ulcer to perforate, and he now had peritonitis. The family consented to surgery to repair the perforation.


The physician and nurses did a more thorough preoperative assessment and asked questions in simpler terms. Hospital protocol also changed, with all patients getting an H2-antagonist (such as Pepcid or Zantac) prophylactically post-op.


The experience increased my confidence as an ICU nurse. I had survived my first code. I had trusted my assessment skills, and the physician had trusted my skills. I had talked to a family about a difficult situation. I remembered what my critical care nursing instructor had told me: "A problem with the gastrointestinal tract can kill just as easily as a heart condition." How true; this patient spent the last two weeks of his life going through disseminated intravascular coagulation and multiple organ dysfunction syndrome. Marvin never regained consciousness.


I gained the respect and trust of the physician and the other nurses that night. I knew I could handle codes. Being a nurse means being there not only for the clinical duties, but also for patients' families. Worrying and grieving with them was okay.


I am sad that Marvin died. But I take comfort in knowing that this experience helped me develop the skills I would need to handle any situation.