Code Sepsis

By: Debbie Moore-Black, RN

It was a known fact. I was 4’11” but I had a mouth on me to compensate. I was loud and noisy. Fellow nurses called me the “Rebel without a cause.”
But I had a cause. I knew I was Samson against Goliath.
Most everything became my cause.
So I verbally fought my way through this iron-clad heavy management structure.
I had to fight for the betterment of the patients. For their survival.
I had to fight for the nurse that was being bullied.
I had to fight in front of an all management team that failed to uphold a safe 2:1 patient/nurse ratio.

I was invited to a grand Sepsis protocol debate.  The Sepsis protocol rolled out around 2003. This big meeting held Critical Care managers from ICU, Neuro-ICU, Coronary Care Unit and The Emergency department, Pharmacists, Respiratory Therapists, ER Physicians, and Intensivists and other important medical representatives across the country.
And I was invited to this “Think tank.”
I was the little fish in this big pond.

“Code Sepsis”
And at this round table with Heath care professionals who were use to pounding their chests on how good they set up this Sepsis protocol, I had to debunk it.

Sepsis was the new named diagnosis and if not treated rapidly and proficiently a patient could die.
Our numbers showed that our patients were dying.
Cardiac patients have the “golden hour”.
The sepsis patient had the golden hour also.
Sepsis: a raging infection that consumes most organs. Bacterial, viral or parasitic infections.
The symptoms: shortness of breath, dizziness, confusion, rapid heart rate, low blood pressure.

At our institution, a sepsis patient stayed in the ER for hours. Strategic life-saving protocols were stalled and when the patient eventually got to the ICU, precious hours had been missed.
We had to intubate these patients. Put in a stat central line and arterial line. Hang vasopressor drips, get stat labs and administer IV antibiotics. And add liters of IV Normal Saline.
The entire body had to be resuscitated.

I mentioned in the round table that we were doing it all wrong.
I recommended  a “Code Sepsis” should be announced overhead. The Rapid Response Team (RRT) should respond to the ER stat. A central line should be inserted stat and an arterial line. Stat labs. To include a lactic acid level, ABG’s, intubation, electrolyte profile, liver function tests, and kidney function tests.
All in all these procedures had to be preformed stat and simultaneously.
But they weren’t. They came to the ICU after being in the ER for several hours. Precious wasted hours. Precious minutes.

The round table got loud and argumentative.
But we began to settle on the truth. That we weren’t being aggressive enough, medically. And our patients were dying.
Protocols were rewritten and added too.
We fine tuned.
As an aftermath of this “think tank”, Code sepsis was now  called out overhead. The RRT showed up in the ER and with rapid succession of intubation and central line insertion, the patient was rushed to our ICU with the goal of one hour.

Feeling that I productively had added my 2 cents worth, 2 weeks later I was called to the manager’s office.
Our manager told me I was brilliant, my ideas were also “their ideas”.
BUT… she had to write me up.
Why?  Because I spoke “out of term”.
I intruded amongst these professionals. I was out of place.
In years to come, at this institution, I realized that they had to be the ones in control. They had to be the ones with the ideas.
I was just that brick in the wall and they wanted me to close my mouth.
I carried on relentlessly for the betterment of the patients and fellow nurses…. Until I could no longer feel any support.

They wanted me to be a yes person.
To serve, honor and obey.

Lesson learned: pick your battles!!

(Google stock photo)

The Fist

By Debbie Moore-Black, RN

I thought it would be easier than ICU nursing. After 33 years as an ICU nurse, I had to leave. I just couldn’t take the pounding on the chests of little old men and women. Hearing and feeling their ribs crack while CPR was performed. I just couldn’t handle these poor patients that should have had a peaceful death when the inevitable was near.
Family members with expectations of miracles. Denial. Rationalization.
And I had to take a break from my favorite dedication to ICU nursing.

Morally, I could not assist in keeping an end stage multi-organ failure patient alive artificially anymore.
So I chose Behavioral Health as my last “swan dance”. Thinking it would be an easier qpassageway to retirement.

But ICU nursing and Behavioral Health Nursing… they are apples and oranges. Both with incredible complexities.

He came to us from jail. He knew the tricks to get out of jail…. Temporarily. He smeared his feces on the walls in his jail cell. He started to talk about the FBI being a chip in his brain and suicidal ideations. And they knew they would have to admit him to our Hospital: Intensive Management Behavioral Health.
He had a long record: Domestic abuse/violence. Rape. Assaults with a deadly weapon.

Upon entrance to our unit, compared to his jail cell, we were nicknamed “The Hilton hotel”. Your own bedroom, with a bathroom and shower. 3 meals a day with interval snacks/refreshments. Medications to calm you down, to help you sleep, to help stop the voices in your head. To help you to relax. Loads of group therapy and gym time. Anything would be better than being in jail.

I always said my “anti-assault prayers” before entering this Behavioral Health unit. Sometimes they worked well for me, for us. But these patients were so random. Anything could be a trigger.

On this particular night, Sam started to act out. He was already very intimidating. He’d stare at the nurses. A fixed glare. He’d have verbal fights with fellow patients…. And then came the chair throwing, and tossing over tables in our community room.
We immediately called our Public Safety Officers (PSO’s) to assist the staff and to protect us and protect the other patients.
I readied my syringe, haldol, Ativan, Benadryl.
The trifecta.
We could not verbally redirect Sam to go quietly into his room.
So the PSO’s held onto him and guided him to his room.
He physically fought his way into his room, attempting to fight off the PSO’s while shouting out obscenities.
And then a calm came over his face.
I had to give him an injection.
He stood perfectly still. Rolled his sleeve up and said “ok, I’m ready”.
A PSO stood on each side of him.
Sam stood perfectly still and stoic.

For a brief moment, we chose to trust Sam. That he was willing to take this injection in his arm.
With my alcohol swab ready, I wiped his arm and then began to aim the needle.
Out of no where, the perfectly still and calm Sam, got his fist and aimed at my jaw.
I saw his fist coming toward me and I remember saying “Oh no”.
The strength in his fist made my entire body crash to the floor. My eyeglasses flew out in the hallway.
A PSO on each side of him, and we didn’t see him coming at me until it was too late.

Our biggest mistake was that we trusted him.

He then began to physically fight the PSO’s. And he was steadied, another nurse gave him the injection and the patient went off to the seclusion room.

I was immediately wheeled down to the Emergency Department. I was uncontrollably crying and shaking. I couldn’t talk. The physician thought the patient had fractured my jaw, I had contusions on the right side of my face. And I couldn’t move my mouth.
They wheeled me in for a stat CAT scan of my head.
Beyond the contusions, the Cat scan was negative. I was lucky.
I took 2 days off of PTO.
And I was back.

But things were different. I was fearful. Of any of these patients. I realized he could have done so much more damage physically.

But mentally, I was now damaged.
Dead bolting my doors at night at my house.
Waking up at 0300 seeing that fist come at me repeatedly. Dreams of unidentifiable men breaking into my home.

Obviously, I was experiencing PTSD.
And I have sought some long-term therapy.
I pressed charges against this man, but then that became a fear also. He could find me. He could look up my address.

My one comfort is knowing that my male
rat terrier dog protects me.
And though he is small, he would go at someone’s jugular for my protection.

It’s not an easy job.
Another real reason that within one more month I will retire from being a nurse.
If the lay people only knew the physical and mental abuse we take 24/7.

You can hear the angels sing

By Debbie Moore-Black, RN

Last night working in the ICU, a male
nurse assistant approached me to tell me he had read one of my stories about how people can die peacefully, without the breathing machines, without the wrist restraints, without the IV’s and mutiple lab sticks. Without the confusion and chaos and delirium that comes with ICU’s.

He said his 89 year old grandmother, who practically raised him, told him that she didn’t want to live forever. That she had a good long life. And she was ready to go “home.”
He said , “working ICU, I didn’t know anything different. I just thought that was the way people died.” …. On a ventilator.
As he read my article: “Go Quiet into the night”, a peacefulness came over him. He wanted his grandmother to live forever, but he also wanted to honor her wishes.
He had dreaded that day that his Grandmother fell ill.
But he loved granny so much that he respected her wishes.

Granny laid in her bed at her home. The window was open as a sweet breeze came through those Irish lace curtains.
“Amazing Grace” through her radio sang.
Granny spoke of her beautiful homeland; the green fields of Ireland. The magic in the air. “When Irish eyes are smiling”🎶…. her devoted pup at her side.. her family holding hands crying for losing granny, crying for granny’s goodbyes.
And they sang softly with her….

Granny reached out and held her husband’s hand through the mist…. the husband she married so many years ago….how she missed him…. as she drifted in and out until she reached her homeland. Her ever-after.
She was finally home.

☘️ When Irish eyes are smiling…..
Sure it’s like a morn in spring. In the lilt of Irish laughter, you can hear the angels sing.
When Irish hearts are happy, all the world seems bright and gay,
But when Irish eyes are smiling, sure they steal your heart away☘️

Dedicated to my twisted, funny, Irish dad!!! I’m sure you are always in trouble!!!