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[Triage Note: Found unresponsive at home, incontinent of urine and stool. Decreased level of consciousness. GCS 13. Medications unknown.]

The third Monday in May, Victor Amelio couldn’t make it down for breakfast. The previous day, he’d planted an entire garden of tomatoes, corn, and squash at the home he shared with his daughter and teenaged grandchildren. At seventy-two, he was in excellent health, taking only a few medications daily – a pill for diabetes, one for high cholesterol, and the occasional Advil. “I overdid it,” he told his daughter, rolling over and pulling a sheet over his head. Rushing to get her boys to school as she readied for work, she brought Victor a glass of orange juice and a slice of toast and left it on his night table.

“Are you ok?” she asked him.

“I’m ok,” he said.

Seven hours later, his grandson returned from school. The kitchen was untouched, the boys’ breakfast plates and cups still scattered across the table. The television was on, poker having replaced the morning sports highlights. The teenager stopped at the bottom of the stairs and called up: “Nono?”

There was no answer.

“Nono!”

He ran up the stairs and opened the bedroom door. His grandfather was spread across the bed, naked. He skin was grey and his breaths were quick. The orange juice had spilled to the floor. There was vomit on the walls and on the carpet. Victor was covered in his own urine and feces. The boy ran out of the room and called 9-1-1, and then he called his mother.

An hour later, Mr. Amelio was wheeled into the emergency room. A violent odor blanketed the department. A nurse called me immediately: “Can you come to acute one? Decreased level of consciousness.”

As I approached, my eyes watered with the stench. I suppressed a gag and took breaths through my mouth. I stopped outside the room, glanecd inside, and saw Mr. Amelio resting atop a large yellow HazMat tarp. I covered myself with a gown, and strapped two masks over my nose and mouth. “What’s the story?”

“No story,” the nurse said, as she clutched his forearm and placed an IV. “Diabetic. Not on insulin. Fine yesterday. Found like this today.”

The cardiac monitor showed one-hundred and forty beats per minute. His blood pressure was low. “Bolus a liter,” I said. I listened to his lungs. I ordered blood work, a chest x-ray, and a foley catheter. I flashed a light into his eyes. “Do you know where you are?”

“Okay.”

“Are you in pain?”

“Okay.”

I stripped off the gown and left the room. “Call me if he worsens.”

He did worsen. Half an hour later, his breaths were labored and his lungs were congested. I was called back. He was clean, draped in a hospital gown, intravenous lines secured in both his arms. His daughter was seated at the foot of the bed. The smell was practically gone.

His daughter stood as I entered the room. “Are you the doctor?”

“Yes.” I glanced at the monitor. His oxygen saturation was falling. He was restless and agitated. An alarm beeped as color faded from his lips and hands. I pulled a phone from my pocket.

“Thank you for looking after him,” she said. “I don’t know what happened. He was perfect last night.” She stepped forward. “What’s going on?”

“I’m not sure,” I said. “He’s not breathing well. I’m going to have to put a tube into his throat and connect him to a ventilator.”

“Oh my God.” Her phone rang, just as I called my colleague, Dr. Argent, to the room. “They’re taking care of him,” she said. “One doctor’s right here and another is coming.”

Within seconds, Argent was in the room, pushing paralytic medications into Mr. Amelio’s intravenous line. I opened the laryngoscope and slid the cold metal blade over his tongue, lifting it away and exposing his vocal cords. The tube slipped easily into his trachea, as his oxygen saturation rose and he settled.

“Thank you, doctors,” the woman said. I left the room, telling her I’d be back when we knew more.

This year, National Nursing week is May 12-18 in Canada. The following is how this case may have unfolded if not for nursing care:

A seventy-two year old patient is brought into acute room one. The doctor is called. The smell of urine, feces, and vomit is overwhelming. The patient is aggressive, disoriented, and confused. His blood pressure is low. His lips are chapped. His heart rate is through the roof. The doctor looks for an intravenous needle. He can’t find one. He calls another doctor. The other doctor can’t find one either. They find a spinal needle, normally used for lumbar puncture, and figure it’s good enough. Doctor #1 holds down the patient’s hand and tries to find a vein. The patient slaps Doctor #1 with his other hand. Doctor #1 falls to the ground. Although he can get up, he plays dead. Doctor #2 looks for the spinal needle.  He notices drops of blood on the floor, follows them, and finds the spinal needle in Doctor #1’s thigh. He leaves it there. He can’t take it out, just as he can’t take out IV lines when patients are discharged home. He finds a proper IV needle and tries to find a vein in the patient’s hand. He can’t. He tries higher in the arm, pokes several times, but can’t seem to thread the needle. He gets a central-line kit, deciding to go for the jugular. The patient is thrashing. There is no IV line to push paralytic medication. He gets duct tape. He tapes the patient to the bed. He kicks Doctor #1 and tells him to get up. Doctor #2 puts in the central line. Doctor #1 tells the fifty waiting patients that everyone will be getting jugular lines today. Heart attack? Jugular line. Abdominal Pain? Jugular line. Cough and cold? Jugular line. They search for medication to push through the line. They can’t find it. The family arrives. They ask what the test results show. The doctors explain that they’re not sure how to submit blood tests. The patient’s oxygen levels drop. He becomes agitated.  Doctor #1 holds the patient’s head as Doctor #2 intubates him with an endotracheal tube. The patient is incontinent of urine. The doctors look for a foley catheter. They can’t find one. And if they could, they wouldn’t know what to do with it. They get another breathing tube, and the metal laryngoscope. They intubate the penis and attach the tube to suction. The family asks if anyone is going to clean the urine and feces from the patient. Doctor #1 runs away. Doctor #2 starts to cry.

Patients and their families often treat physicians better than they do nurses. I’ve seen patients kick, hit, spit on, tackle, and slap nurses. Just last week I saw a patient beat a nurse with a telephone. The same patients can be kind and gentle when a physician enters the room, thinking that we are the key that will unlock the door to good health. They should think twice. As highly-skilled, front-line health professionals, nurses often save lives long before physicians have a chance to enter the room. While the above depiction may be a little far-fetched, I can’t imagine what it would be like to work in a busy ER without the great nurses I have the pleasure to work with every day.

Two hours after his arrival to the ER, some of Mr. Amelio’s test were available. A CT scan of his head was normal. The chest x-ray was also normal. His blood work was indeterminate, showing only that his heart and lungs were failing for reasons unknown. An hour later, his temperature spiked and broad-spectrum antibiotics were given. A spinal tap was performed – no signs of meningitis or encephalitis. A tox-screen was negative; there were no illicit substances in his blood, and there were no signs of overdose. He was kept sedated and ventilated, and just after midnight, he was transferred to the Intensive Care Unit. Over the next twenty-four hours, his condition worsened: He developed seizures, and his kidneys deteriorated. He required a constant infusion of medication to maintain his blood pressure. He was treated with dialysis and further antibiotics. A blood culture drawn at initial presentation grew bacteria: Mr. Amelio was septic, his body overwhelmed with Staphylococcus. The origin of the infection was unknown. This is the way it is in medicine. Sometimes, things just happen because they happen. More antibiotics were given. Mr. Amelio’s body failed to respond.

The patient’s family flew in from different parts of Canada and the United States. Twenty-four hours after coming to the E.R, Mr. Amelio was still intubated, needing constant ventilation to stay alive. He developed myoclonus – involuntary twitching that confirmed deteriorating neurological function.  The family met with the ICU doctor and all agreed that withdrawal of life support was in order. Medications were withdrawan. Ventilation was weaned. Mr. Ameilio was dead within an hour.

Thank you to all the fantastic nurses who have helped me, and, most of all, helped patients for as long as I’ve been doing this (and longer).

Happy Nursing Week.

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2 Comment on “Case 5: Without Nurses…

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