In 6 years, never have I ever…(Day 3)

I have been an ICU RN for 2 years, a nursing track I never saw myself going into. The first day that I has an ER clinical I knew I would never do anything else. Oh how time changes us all!

In my first year of ICU nursing I had a patient that went into respiratory failure, was intubated, and developed ARDS. Our attempts to recover this patient were proving to be futile, to include paralyzing her to TRY and overcome ARDS. Knowing that we were nearing the end of our clinical intervention course the patient’s family decided to make the patient comfort care the next morning at 10am. The night they made that decision I was in the room and I told them, ‘I’ll take care of our girl.” Around 2am I wanted to clean up the patient. I wanted her bed to face the window so she got the sunshine on her face one last morning. I wanted her to be in clean sheets and clean clothes. I wanted her to resemble the peace I was hoping she would leave this world with. I gathered my team of a PCT and another RN as I prepared to turn the patient. I had to ETT and the vent circuit to my right, as I always do. I had her airway, I ALWAYS control my patient’s airway. Always.

As we laid my patient back onto her back and prepared to move her to the other side to place the clean sheets my ventilator alarmed me of low tidal volumes. My patient wasn’t on sedation, there was no paralytics. She hasn’t moved and yet something wasn’t matching up. I immediately tried to give her 100 FIO2 giving me time to find the problem. I scanned her head to toe, I looked for a disconnect somewhere then I saw it. Her ETT had slipped out. What you need to know is that in 6 years, I  have NEVER lost an airway. I thought I was diligent, careful. I had never been faced with this problem and I didn’t know what to do. She was a DNR, surely we weren’t reintubating her. In a flash I pushed the tube back back ‘down’. Surely it wasn’t out that far. But her volumes didn’t improve. Her O2 saturating was falling.

I called a rapid response. In an instant I was surrounded. I told everyone what happened and the current plan of care.  Meanwhile, her vasopressor was maxed as my patient’s circulatory system began to suffer. Wtih RT bagging the patient I went to reassess my patient and the teams effort and noticed my patient’s stomach had grown considerably, the ETT I pushed back in…..was in her esophagus. While speaking to the patient’s pulmonologist on the phone I realized my mistake. “We have to extubate.” Every eye shot over to me as I repeated my words. The pulmonologist agreed BUT we weren’t going to reintbate.

I had to make a call I am familiar with but have never done because of an error and I was flooded with; fear, sadness and emotion. I started as I always did, “This is Leighann, there has been a change in the patient’s condition…” but this time I had to tell them that her ETT had shifted and she was no longer getting oxygen. The remedy was to pull it out and reintubate her which 3 doctors were advising against. The husband agreed to extubate her. I heard him getting into his car, he’s on his way.

It happened in slow motion, we extubated her. I saw her O2 saturations drop. I watched her BP begin to sink on the monitor to question marks and there was silence. My patient was pronounced dead at 0234. She never got the clean clothes, the sun on her face.

I have NEVER lost an ETT in my career, until this day. Months later it became a review case where other nurses are faced with the same situation and they have to decide what to do, this is called a Mock Code Blue. I was never warned it would become an example.

The night my patient passed away I cried. I was angry at myself and I was sad for my patient and her family. They had a plan and a way they wanted to do something and I go in the way of that. There was no debriefing. No huddle afterward. I walked out of my patient’s room, gathered myself for a few minutes and walked right into my other patient’s room to check on them

One of the pearls that I am going to take away from this conference and that night was that care for the caregiver program is a MUST in all healthcare environments. To extend that, it needs to be offered to everyone; practitioners, nurses, PCTS, hosekeepers, dietary because our interactions to the patient’s aren’t limited to just a practitioner and RN. After an emotional night, that doesn’t even have to include the loss of a life, people need to have and to be aware of the resources that surround them.

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