Angela Voto

10/24/14
BMC CCU
Clinical Exemplar
PATIENT: 35-year-old woman with asthma and sickle cell disease who was admitted for pain crisis and possible acute chest
syndrome. The patient presented with diffuse body pain over the last few days and she also noted significant pain in her chest.
She reported that the chest pain had been a feature of acute pain crises for her in the past. She was noted to have a chest
infiltrate in the emergency department and had been being treated for vaso-occlusive crisis and lower lobe pneumonia.

It was just like any other start to the night shift in the CCU at Boston Medical Center. I
had received one relatively straightforward patient as my assignment and I was expected to take
an admission into my other empty room at some point during the night. Since an admission can
be quite time consuming, after report, I immediately went in to do a head-to-toe assessment on
my current patient and administer night time medications in order to make sure that I was ready
when my other patient arrived. Just as I was about to scan the patient and the medications, I
heard that all too familiar dinging over the intercom. The operator calmly repeated the phrase,
Adult Code Blue, Adult Code Blue, Adult Code Blue, followed by the specific unit and
location. Per protocol, the charge nurse in the CCU is required to travel to the other unit to help
out during a code, so being a nursing student, my preceptor knew it would be a great learning
experience and sent me down with her. By the time we had arrived, it was complete chaos;
nurses, fellows, residents, respiratory therapists, aids etc all swarmed the patients room trying to
find a task to make themselves useful.
At this time, the patient was unresponsive and did not have a pulse. CPR was preformed
for a short period of time, the patient quickly regained her pulse, and the anesthesia resident
intubated and ventilated her. The patient was now stable and although this was not technically a
CCU patient, we often get overflow from the MICU, so you guessed it; this was my new
admission. I followed the rest of the team back up to the unit to settle the patient and receive
report from the current nurse. I discovered that the nurse had paged the physician prior to this

incident informing him that the patient appeared less alert than usual and that she thought that the
rate of the morphine PCA pump should be decreased. Based upon this information and the fact
that the administration of narcan proved effective during the code, the respiratory failure was
likely secondary to the administration of excess opiates. The plan now for this patient was to get
weaned off the fentanyl and propofol drips with the hopes of extubation in the morning
depending on the improvement of her respiratory status and results of the chest x-ray.
There are many reasons why this particular patient and this particular event were
significant to me. First and foremost, this was my first experience with a code. I will never forget
the adrenalin rushing through my body as we raced down the stairs to offer assistance. I will
never forget seeing the devastating face of the nurse that was taking care of the patient at the
time. In that moment, I thought to myself, what if that was me? What would I do? I sympathized
with the nurse knowing that I would be feeling just as overwhelmed as she was in this situation
and probably wishing I had done more; wishing I had paged the physician one more time and
insisted he assess the patients status STAT. After this experience, I thought about how no code
is perfect and there is always something to be learned and take away from the situation such as
ways to improve upon for the next time. For instance, in this situation most of the members of
the team agreed that maybe they should have waited to intubate and that maybe the patient would
have come out of it on her own without ventilation. Something that can be learned here is that
although it is an emergency situation and you are required to act fast, you should make sure that
the intervention is appropriate for the patient and the situation.
In addition, this situation was significant because after all the chaos was over and after all
of the physicians quickly assessed the patient and rushed off to write orders, it was just me left.
When it was all said and done, just me (the nurse) and the patient remained. It was amazing to

me how it went from being so chaotic to eerily quiet within minutes. Although the patient was
stable and essentially everything had been taken care of such as hooking the patient up to
telemetry, obtaining vital signs and an EKG, setting ventilation alarms and parameters,
administering medication, inserting a catheter, etc., there was still so much more to be done. The
patient remained there, diaphoretic lying uncomfortably on damp linen with tears dried up on the
corner of her eyes and pink-tinged drool, most likely from the trauma of the insertion of the
breathing tube, spilling out from her mouth. In this moment, I realized this is why I chose the
career path that I chose; why I chose to become a nurse.
Of course I love the medical aspect that being a nurse entails. I love learning new
information on various diagnoses, treatment options, or medications and their pharmacology, but
what I get pleasure from the most is knowing that I can make a difference in the lives of my
patients and their families. I could make a difference for this patient by simply changing the
linen, providing daily care and mouth care, and repositioning her. It was gratifying and fulfilling
that regardless of this horrible situation, the patient could not have been more appreciative.
Although she could not communicate verbally due to the breathing tube, she continued to mouth
thank you and I love you while gesturing her hands in the praying position. I could not
believe how grateful she was of the little things that I did for her such as place a cool face cloth
on her forehead, wipe the dried tears from the corner of her eyes, or reposition her in a way that
was more comfortable. It was satisfying to know that although I could not remove the breathing
tube like she wanted me to, I could still ease the pain of the situation through small interventions
that did not seem like much, but made a world of difference for this patient.
What was most challenging in this situation was having a patient that was intubated and
restrained who for the most part was completely alert and oriented. Although the patient was on

continuous intravenous fentanyl and propofol drips, due to her history of sickle cell disease and
chronic administration of pain medications, she was not as sedated as most patients receiving
these medications would be. I could not imagine how uncomfortable she was with the breathing
tube in place in addition to being unable to use her hands due to restraints. This was quite the
learning experience for me because I did not realize that you could have an intubated patient with
that level of alertness. This experience has taught me the importance of communicating with my
patients everything I am going to be doing to them regardless of whether or not they are
sedated. Many times I will see nurses and physicians perform tasks on sedated patients without
communicating to them, but this situation has taught me that you can never assume this.
This situation was different from other student experiences for me because up until this
point, I felt as though I have always been the student. In this situation, I really felt as though I
was the sole nurse taking care of the patient. I felt as though the patient and I shared a
connection, especially because I took care of her for the two nights she remained intubated.
Furthermore, this situation enhanced my transition to the role of a professional nurse because it
has made me realize the importance of advocating for your patients when they cannot advocate
for themselves. It was my job to request orders for an increase in pain medication when I noted
the patient was becoming uncomfortable and it was my job to push for the removal of the
breathing tube as soon as possible in order to speed up the recovery process of the patient. Most
importantly, through this experience I have come to realize what a difference it makes when we
learn to see a patient not just in terms of their illness, but as a whole personsomeone with
hopes and dreams to fulfill; someone with a life to live. Knowing this to be true, I embark upon
my own educational journey with a strengthened confidence to be the best nurse I can beone
who makes a difference in the lives of others.