Nurses Impact Lives Beyond: Case Studyd

Nurses Impact Lives Beyond:
Case Study
Nurses Impact Lives Beyond

Pre-hospital Phase:

It was cold and dark, when the helicopter was dispatched to a scene flight for motor vehicle crash with double entrapment one May morning at 0230. Two of the three patients, are unresponsive and in critical and unstable condition. This is the first encounter our patient would have with a registered nurse providing and directing his care. The nurse possesses both acute care and pre-hospital expertise and would work collaboratively with police, fireman, good Samaritans, EMT’s and paramedics to access the patient, provide timely triage, life -saving interventions and rapid transport to the closest trauma center. Each team member has a pre-defined and respected role; the nurse is the senior health care provider and assumes the leadership role with a calm, confident demeanor that is reassuring to the team.
This patient was a 25 year old man, unrestrained driver of a vehicle that hit a brick wall head-on at a high rate of speed. Of his two passengers, one of them is a brother, all require 20 minutes of extrication time from the severely damaged vehicle. After freeing our patient, the team works together to assess and stabilize him. His initial vital signs are worrisome, with a BP of 140/80, pulse of 160 and spontaneous respiratory rate of 8. The nurse assumes his care and quickly supports his respiratory rate by bagging and suctioning blood from his airway then inserting an ET tube to ventilate through. A team of 2 EMT’s assist to immobilize him on a spine board, stiff-neck collar, and CID blocks. The patient responds only by flexing to pain, no eye opening or verbalization. His noted obvious injuries are large head laceration approx. 6 inches in length, a head injury with his decreased level of consciousness, left lower open leg fractures and potential intra- abdominal injuries with persistent tachycardia. He is placed on cardiac monitoring and two intravenous lines inserted to give boluses of IV fluids, obvious bleeding from his head and leg fractures is controlled by pressure and splints, then our patient is loaded onto the aircraft. Another vital function of this nurse is to call an accurate report to the receiving Medical Center, answered by an Emergency Dept. Attending physician to give further orders and assemble the responding Trauma Team to assume the care of the patient.
The pre-hospital nurse spent 15 minutes with this critically-injured patient. It was the first link with the community resources, the patient and the trauma system and would determine the next steps of the rest of his life. Although it was 15 minutes of initial patient contact, this nurse will dedicate many more minutes to this patient. Fully documenting his care and treatment, reviewing and submitting it to the flight quality program, and then to the multidisciplinary trauma review team process. After the shift, the review of events continues to play over and over – considering his presentation, and the actions that resulted. All the time supporting him as a person – he is someone’s loved one. They are being notified that life before they went to sleep, is very different now.

Emergency Department (ED) Resuscitation Phase:

A Level I Activation was paged due to the report of the patient’s condition to the Emergency Attending physician. This is the highest level of trauma team response, and requires all members to assemble at the bedside of the patient within 10 minutes of his arrival. The goal of this multidisciplinary team is to assess, intervene and treat life threatening concerns, select most efficient diagnostic test and expedite the definitive care of the trauma patient. The Emergency Department (ED) Nurse is a vital component of this team, utilizing assessment, critical care and communication skills to maximize all team members’ contributions. The ED Nurse is a consistent core team member that travels with the patient, not only providing direct care, but also diligent monitoring and documentation of the patient’s response to treatment. Our patient arrives with a pulse of 165 – BP 97/52 – no spontaneous respirations and a temperature of 34.9; his pupils are equal at “2” and reactive to light. The team is preforming simultaneous task… a primary survey, secondary survey, a large subclavian central line is placed, labs are drawn, warm blood is hung, C-spine, Chest and pelvis X-rays are taken, an A-line is started, a left sided chest tube is inserted, a pelvic binder is applied, his scalp laceration is stapled to control an increase in bleeding and the chaplain is diligently pursuing identification of our patient. 15 minutes has gone by and injuries known thus far: blunt head injury with coma, mandible fractures, L pneumothorax, pelvic fracture, femur and tib/fib fracture, probable intra- abdominal injuries are suspected due to the persistent tachycardia of this patient. His ED nurse is monitoring and documenting all of the team’s actions and the patient’s response, still wondering if he has a family getting an awful call in the middle of the night and thinking they would not be relieved by getting to the hospital and discovering that his condition is better than they feared. It is time to take the patient to CT scan and evaluate his brain and other unknown injuries. A core team works diligently to protect all the lines, tubes and most importantly the patient during these critical diagnostics. His ED nurse is glad to see a veteran CT tech is on and can be of great assistance in quick scanner of this critical patient. Together they survey his IV site patency, body positioning and quickly begin the scan.
Findings during the CT scan: A serious head injury with bleeding of the brain, multiple facial fractures, multiple fractures of the right hip/femur and tib/fib, a comminuted pelvis fracture with life-threatening bleeding observed coming from the pelvic arteries directs our patient to another trip for an attempt to control this bleeding by inserting a balloon and embolizing or cutting off the vessels bleeding. Also concerning on the scan of the chest is a potential tearing of one of the vessel feeding the aortic arch. The core team continues evaluation, blood product administration, and protecting the patient from further loss of body temperature or harm that could affect his condition.
The next safest destination for our patient is in the Operating Suite. This state of the art Trauma Center has developed a unique protocol that allows for seriously compromised patients to have interventional radiology procedures in the operating room where they can be operated on immediately if these procedures fail to stop the bleeding process. It is @0535 and time for his ED nurse to turn care over to his intra-operative nurse and team, there is relief and reflection. Most prevailing is a bad feeling for the recovery and the family left to deal with the grief of such events. How lucky our team is for having a dedicated individual (our chaplains) to provide individual attention to these circumstances. The family had been reached, given the information provided by his conscious brother who arrived last to the ED @0415.
His parents arrive at the hospital @0545, the chaplain escorts them to a private area, and the Trauma Attending physician and ED Trauma nurse are there to give them an update on their son’s condition and progress to this point of this care. The news is grim, the worst thoughts that raced through their heads is true. The parents then return to one comfort, another son in the ED surviving the crash that can talk to them, give those further details and hope for the future. The chaplain again is there to escort them to the Surgical Intensive Care Unit (SICU) waiting area, a place they can be reached for potentially better news of their son’s progress and a prayer.

Intra – Operative Phase:

Our patient underwent pelvic arteriogram revealing traumatic injury to the right internal iliac artery and the left internal iliac artery both were successfully treated with gelfoam embolization and his shock state was stabilized. He then underwent further diagnostic angiogram to rule out an aortic dissection, which was not evident and allowed his orthopedic issues addressed in a first stage process.
Neurosurgery was consulted in the Trauma Bay and placed an intraventricular pressure monitor to treat intracranial hypertension as a result of his brain injury.
The Orthopedic injuries are addressed by irrigation and cleaning out of the R hand wound, L ankle fracture, external fixator applied to the L tibia and traction pin to give longitudinal traction of the R hip/femur fracture. Due to the critical condition of the patient and ongoing hemodynamic resuscitation of blood products further orthopedic repair and fixation will be done in a second stage procedure.
The Operating Room (OR) team is multi-disciplined with well- defined roles. The OR nurse is constantly counting, documenting the instruments and equipment to keep the case going and patient safe.

The Critical Care Phase:

Our patient is immediately transported to Surgical Critical Care Unity (SICU) at the conclusion of the OR case bypassing the Post Anesthesia Care Unit (PACU).
On his arrival the SICU nurses and respiratory therapist expeditiously transfer him to his bed and do an in-depth assessment of his condition.
The nurses are experts in critical care with all its new technological advances and thrive on challenging cases; this knowledge also prepares them for the cases that have a high probability of death. Their patient has had significant insults to his body’s systems and one treatment is in constant turmoil with another system. His shock state has been successfully treated with blood and fluids, but his brain injury is swelling in response and requiring drainage and diuretic drugs to reduce his brain pressures.
It is an internal battle, one that as time marches on our patient appears to be losing.
These experienced nurses have dealt with many life and death situations; one that they fiercely protect is the right of every person to have their wishes carried out when they can no longer voice them. Their families become that voice. The nurses had made a call to the designated Organ Donor Program when the brain pressures kept rising and not responding to any treatment measures. It is a federal law that each person’s wish for organ donation be explored at their time of death and timing is imperative to the possibility of many donations.

Our patient’s family has been brought in to his bedside, observing for themselves the battle that has been fought by their loved one and his care providers. In this case, his closest next of kin are his parents. Every worst parent’s nightmare has come true for them, an emergency notification call in the middle of the night, and now facing the possibility of surviving one of their own children. In many cases the ability to participate in the patient’s care decisions and witnessing all that is done to maintain a severely injured person allows families to accept that nothing more could have been done and they begin a grieving process.
The next nurse that our patient and family encountered was the Transplant Coordinator from, the Regional Organ and Tissue Transplant Network Program.
Fortunately for these parents, their son had recently voiced his wishes for donation, giving them a focus on something positive that they could make happen out of this tragic event for their son.
The Transplant Coordinator and SICU nurses and many other hospital staff worked diligently to maintain perfusion to the patient’s organs after he had met brain death criteria.
This process of consenting, consulting, more diagnostic work up, organ harvesting team organization, further operating room resources and transport of several retrieved organs came together in the next 24 hours.
The outcome over the next 24 hours has affected the lives of many people…..and their nurses: * The left kidney went to a 10 year old boy, who lives in the same state and attends the 4th grade. He was on the waiting list for over one year and just about ready to start dialysis when he received his gift. He is a Cub Scout and loves to play video games, he also adds that he loves to play with his family and feels great now that he his new kidney. * The right kidney and pancreas went to a 30 year old woman that also lives locally as well. She has been very ill and unable to work recently receiving disability. She is doing very well and expected to make a full recovery. Her goal is to return to work with a renewed health and fuller life. * The liver went to a 65 year old gentleman that has the joy of a new granddaughter. He has been discharged from the hospital and is recovering at home. * His heart was a directed donation given to his 50 year old uncle and is doing very well in recovery. His mother has gone to visit him and place her ear on his chest to hear the heart of her son beating.

As this event first occurred during the early hours of that May morning – it triggered a multitude of diverse resources and responses. During every phase of care a vigilant professional presence of nursing was by his side. Providing the appropriate interventions, evaluating their effectiveness, and protecting from further physical, emotional and spiritual deterioration and harm. As this story and events unfolded – nurses will continue to support this patient and those his life and death touched beyond.