There Are No Simple Cases
Submitted by There Are No Simple Cases
by Barbara Tate ASN, RN
Tampa General Hospital
As a twenty year experienced recovery room nurse, I know that no case is ever the same. People are individuals. They react differently to medications. They metabolize drugs at different rates depending on age, body mass, body temperature, kidney and liver functions. Although everyone is different, I can basically expect a certain outcome in recovering people. But in saying this, you can always expect the unexpected. People with long medical histories or extensive allergy list (we've all seen them), generally make the hairs on the back of my neck stand up. The longer I stay in PACU, the more I get a sixth sense of trouble coming. There was one case that completely caught me off guard. I never saw it coming and would never again think any case was simple.
This specific case occurred while I was working at a wonderful 250 bed hospital in northern Indiana. After working for years in a large trauma center PACU, this is what I thought of as the perfect job. Our recovery room was only four beds maximum and usually only 3 beds were utilized. The nurses in this unit, except for me, had all gone to the same high school and college. The doctors and anesthesiologists were in some cases third generation. The atmosphere in the unit was professional, but very friendly.
This particular day was a slow one. Only two RN's were in the recovery room due to a light schedule. The day was going smoothly. We were about half way through with our few scheduled cases. At the time, the PACU was empty while we were waiting for our next case to arrive. The OR circulating nurse called into the recovery room and requested that a bed pan be ready for the patient when they arrived. She stated that the case had gone on longer then expected and that the patient needed to urinate badly. I checked the OR schedule and determine that this was a foot surgery case. We were informed that the anesthesiologist had done an ankle block with some light IV sedation only and the patient was awake. I replied back that we would have the necessary supplies waiting. It is difficult to place bed pans under patients while a procedure is going on, but not impossible. I have done some circulating in the past myself and have done it. The doctors hate it and so we try to avoid doing it. I could only imagine the discomfort this women was experiencing.
Minutes later the patient rolled in with the OR nurse and anesthesiologist pushing the bed. We could see the distress on the patient's face at the need to void. I quickly positioned the bed pan under her as the second RN applied the monitors. Anesthesia gave me a brief report as a 54 year old female with no significant medical history. Anesthesia then left and the patient finished voiding with a great sigh of relief. I removed the bed pan and measured out 800 cc of clear yellow urine. That's a full bladder for anyone. Then with the assistance of the second RN, I pulled the patient up in bed and got her settled. The patient was very alert and awake. Vital signs were stable and within normal limits. She required no oxygen. We checked her orders and allergies and then hung Ancef IVBP per her surgeons orders.
Things were quiet and my second RN asked if she could step next door and grab a cup of coffee. I didn't think twice about telling her to go ahead. The patient would not be staying long and I could finish up. I finished assessing the patient and then positioned her foot on a pillow. Her dressing remained dry. I looked down and started charting on a bedside table next to her. As I was charting the patient commented to me that her stomach hurt. This perplexed me, due to the fact that she had her foot worked on with no general anesthesia and very little IV sedation. I commented back to her, as I continued to chart, why would her stomach hurt. When I got no answer back, I looked up at the patient. Her head had fallen back and her eyes were rolled to the back of her head. She still had a heart rate and BP on the monitor. I assessed quickly that she still had respiration, but was totally unresponsive. I threw some oxygen on her by nasal cannula and called stat to the OR for an anesthesiologist and assistance.
The response I got was immediate. The double doors of my recovery room boomed open and six OR nurses came flying through. Overhead the call for anesthesia stat to PACU rang out. My poor coworker who had gone next door for coffee, came running behind with a shocked expression on her face. I can only imagine what my face looked liked. They were asking what happened. I hadn't a clue. By this time the patient's respirations began to deteriorate and her heart rate started dropping to the 40's then the 30's. The code cart had been brought to the bedside. I've been ACLS certified for a couple of decades and asked for atropine, since anesthesia had not shown yet. We went ahead and called a hospital code Blue also. Usually in most recovery rooms anesthesia handles our codes, but by doing this I was assured that the ER doctor would be coming immediately also.
The anesthesiologist came in at that time and I relayed the events that had occurred and verified the okay for atropine to be given. I thought of the Ancef that I had just given prior to this and conveyed a concern of a reaction. The atropine was given and the heart rate had increased to the 60's. Fluids were wide open and we were ambuing the patient with 100% oxygen. The code team then arrived with the ER doctor. Although the patient had a pulse, it was weak and thready and almost indictable. We were unable to get a blood pressure at this time. PEA was determined and we begin CPR. I use the older term PEA which stands for pulseless electrical activity of the heart. The newer term is EMD, electromechanical dissociation. This means that although the electrical activity that regulates the heart to beat is working, the heart itself physically is not. This generates no cardiac output thus no blood pressure. There are many causes for this to happen and we had to figure out what it was and fast.
There must have been 20 doctors and nurses in my tiny PACU at that moment. As the Code Team took over, I started to feel a little shocky myself. I was desperately trying to rule causes out in my head. I was glad the ER doctor was there because he immediately started thinking hypovolemia and hemorrhage. He called for the ultrasound machine stat from the ER. We drew labs and an ABG. About that time in came the Podiatrists who had worked on her foot. When they saw the events that were occurring they causally mentioned that the patient did have a history of a small 4 cm aortic aneurysm.
Ding, ding! The bells and whistles started going off in my head about that soft statement that my patient had made to me abut her stomach hurting. The ultrasound machine arrived at that time and confirmed a rupture in the aortic artery. Blood arrived, thanks to the ER doctors foresight, and we began pouring it in. We then obtained a blood pressure and pulse not to long after. We stopped CPR. Amazingly enough the patient then woke up and ask what happen. An OR room was prepared for surgery. At this time, though in a small hospital we had no vascular surgeons or cardiac surgical units. Our general surgeons explained this to the family and the unlikely success of them attempting it. The family agreed and the surgeon requested a transfer to a larger facility. The patient was stabilized in the PACU then sent to the ICU. Unfortunately, she coded and passed away before she could be transferred.
As a seasoned recovery room nurse, I questioned why this had happened at that precise moment in my recovery room. This was just a simple foot case. The other nurses told me it was just fate. It could have happen on the street. Had not allowing her to urinate earlier have caused it? Everyone says no, but I always wondered. I like telling this story to other nurses, especially the younger ones. This taught me to look outside the box and PACU for the answers. I was so grateful to our ER doctor's observations. It reminded me how important it is to keep an open mind and rule out the causes for PEA. It will guide you to the right conclusion and treatment.
As a reminder to all, the causes of PEA also known as EMD (electromechanical dissociation) are as follows according to the American Heart Association ACLS standards: Hypovolemia,(which is the most common cause), hypoxia, hypothermia, hypokalemia, cardiac tamponade, tension pnemothorax, massive pulmonary embolism, coronary thrombosis, drug overdose (tricyclics, digoxin, Beta blockers, calcium channel blockers), acidosis (usually preexisting), and an acute massive MI.