Vital Signs

On a busy day, it is easy to depend on the bright screen in the middle of the main area that shows patients' vital signs when they are hooked up to our monitor system.  Instead of having to trudge down the hall to a curtained room to see someone face-to-face, you could just pull the information from the screen.  Blood pressure, check. Pulse, check. Breathing rate, check. Pain level? Eh, just scribble something down.

Part of being a good tech, however, is taking those extra few steps to make sure your patients are comfortable, and more importantly, doing well.  The other part comes with experience- it has been almost a year since I began as a tech and I am developing an instinct for recognizing when someone is about to crash.  Mrs. Blotchy did not look well.  I knew as soon as I laid eyes on her. Although she was rather short of breath, she answered me crisply and politely.  I looked at the monitor and her breathing was in the high 30's-low 40's.  Other than her high breathing rate, there was nothing else in her vital signs that was exceptional.  I had seen much worse than her, but there was something about her that I can't quite put into words- my gut instinct formed the words before I could stop it. "She's going to get intubated, don't ask me why, but I can tell," I murmured to Newbie.

The nurse took his time putting her on oxygen and getting labs, but in my heightened alertness, I performed Mrs. Blotchy's EKG deftly and tracked down the attending.  The doctor was talking with another doctor about non-work-related subjects as I fidgeted and waited for him to sign the EKG, which contained irregular, non-sinus rhythms.  His distraction irked me and I used that as an opportunity to teach Newbie to make sure the attending always signs paperwork that is presented.

When I returned to Mrs. Blotchy's side, I asked her if she needed anything. Oh, no, she replied, I'm... quite all right, just a little... short of breath.  I felt her hand- it was cold. I grabbed her a blanket.  Her breathing had dropped to 25 breaths/minute. Usually, we are taught that people breathe at 12-20 breaths per minute. On monitor, she was pitch-perfect. She seemed to be getting better, right? Her color, however, told a different story. She was paler than before. Purple splotches were beginning to collect in mottled patterns on her ample flesh.  I alerted the nurse, and soon, we moved her bed to an open room near our nursing station.  Her heart rhythm was now settling into a very irregular pattern and the rate was quickening.  In a mere moment of suspended time, the whole room seemed to come to the same conclusion and everyone rushed toward her bed.

I grabbed the code cart and as soon as I made it to bedside, I heard "do you feel a pulse?" A nurse dug her hand into Mrs. Blotchy's inner thigh to feel for the femoral artery.  "No pulse," she reported. The attending physician folded his hands behind his back and stated calmly, "begin compressions." A male tech was at the bedside and began the violent rhythmic thrusts.  As the doctors at the head of the bed began the intubation process, the nurses were at the sides, trying to establish peripheral IV access to no avail- Mrs. Blotchy's heart was no longer perfusing her circulatory system. I ran for the intraosseus gun, which shoots an IV directly into the bone, oxygen saturation probes, saline flushes, defibrillator pads... In passing, I heard "Oh no, I never saw an EKG for Mrs. Blotchy," from the attending to my manager. I smiled at Newbie- lucky I had the doctor's signature- otherwise I might have lost my job in that moment.

"Halt compressions," we heard. Wiping sweat from his brow, the other tech stepped down.  It was my turn. I hadn't gotten a chance to put a gown on yet.  I climbed onto the bed, wedging my knee by her sweat-soaked side as the ultrasound probe checked her heart for activity. "Resume compressions." I felt her ribs crackling under my hands; the compressions had broken them.  The cold ultrasound jelly smeared onto my forearms as many hands moved around me. "Halt compressions."  A pulse had returned! Our happiness was short-lived as it slipped away once again just as quickly.  Mrs. Blotchy's face was now a deep purple. "Resume compressions." And so my sole concentration and purpose dangled on the thin cusp of life and death for a complete stranger. Yet she wasn't a complete stranger. We were intimately acquainted- as physically intimate as it was possible to be. I was pumping her heart for her and it was slippery, hard work.  She was defibrillated several times.  After about half an hour, I nudged Newbie to line up and I passed the baton. It was his first time, but he was good at it.  It was then that Mrs. Blotchy's daughter was escorted into the room.

She nearly collapsed from the shock at the sight- hanging onto the arm of the nurse manager.  "That's my mother in there!" She sobbed. The attending asked the nursing staff to give full report on the rounds of medications administered so far.  I don't think the younger Ms. Blotchy heard any of it.  The debris from a million packages littered the ground and bed. Newbie was doing compressions and six other hands were on the body of the woman who raised her.  "Please, please," she begged, "Please God don't let this happen to me, please." We defibrillated her for the fifth time.  "I didn't even get to say good-bye! Please, don't let this happen, please!" The doctors looked around uncomfortably. The monitor was still beeping with what seemed to be a pulse.  It was not a pulse, unfortunately. The ultrasound confirmed it. The only rhythm were agonal spasms in the heart muscle. This was one heart that would never beat again.

As the time was called, I could hear a rush of blood in my ears.  I always get that sensation in the surreal, suspended minutes right after everyone else exits the room.  As we began the process of preparing the body for viewing behind our curtain, the room around us was already noisily reorganizing itself.  The cycle of life and death revolves quickly in the emergency room.  I gave Newbie a pat on the shoulder. He had done well and learned a lot. If nothing else, he should remember that when taking vital signs, one should always assess the patient and not the monitor.

S