Do You Feel What I Feel?

Nursing intuition is a nebulous thing, much like a slightly distorted Spidey sense.

There are many theories on what it is that gives us the intuition - is it ESP, heightened perception, finely honed assessment skills, or education and experience coalescing in the subconscious? It is not well explained or understood, but the phenomenon of the ICU nurse placing the crash cart outside the stable looking person because of a 'feeling', and using the same cart to resusitate the patient a few minutes or hours later, is well known.

Usually the traditional methods of knowing when to worry work for me - the pulse of 210 in a non-febrile child, the bp of 80/60 in an adult, the ashen grey and diaphoretic look or the staring, drooling look, and so on. There are very few times when I have had to rely on instinct to guide me in my care.

This feeling occasionally is present because of something totally unrelated to the medical reason for care, such as the man who was using his wife's visit to hospital as an opportunity to steal a couple wallets from the cupboard at the nursing station, or the family member with some form of PTSD (post traumatic stress disorder) having a flashback while visiting.

On the other hand it may be specifically related to the reason for the visit, such as the pregnant mom who presented with the concern of decreased fetal movement. I would ordinarily have taken the time to assess this mom for labour and to check for a fetal heart rate. For some reason I skipped these steps and took her directly to the Birth Unit. Her baby was in severe distress. A very sick but alive baby was delivered by Cesarean Section less than 15 minutes later. Another time there was the suicidal teen who denied having any drugs or weapons in her posession. Ordinarily I would give the teens privacy while they changed to a hospital gown but something told me to stay in the room with this girl. I was quite glad I had when a bag of pills and a razor blade fell out of her bra while she was changing. Then there was the lady with the very nonspecific and vague mid chest pain with no other symptoms who checked out as completely healthy and was sent home. For some reason I made a special point to stop her before she left the department and reiterate again that if this got worse or changed in any way she should immediately return to hospital. Not four hours later she took an ambulance to an alternate facility where she was diagnosed with a large pulmonary embolism. She was in ICU for over a week for treatment and recovery from the complications.

Most physicians and nurses have come to recognize that this nursing intuition is a very real phonomenon and have learned not to ignore it. This is particularly true in a critical care environment.

Because of this culture and belief in trusting ones insticts, I was surprised when I recently found myself in a very uncomfortable spot. A colleague I didn't know well presented for care with a variety of very unusual symptoms. The doc did some basic testing but was actually quite blase about the whole affair while I felt like I was on red alert for the entire time this patient was in my care. While I was quite calm in my presentation of my concern, I'm sure that a large part of the physician's low-key response was specifically because he felt I was overthinking the situation. It was both frustrating and frightening to have such a strong reaction downplayed by the physician.

I still do not know what caused my concern. The patient went home with a nebulous 'NYD' diagnosis and to the best of my knowledge nothing bad has come of this. However, I have not been able to get this patient out of my mind and I was left with the very unsettling feeling that I had missed some very important clue.

What I do know is that on the rare occasion when my Spidey senses tingle, I'd better listen. When my gut is telling me something is wrong or the hair on the back of my neck stands up I know that there is something important and potentially dangerous that I have missed. Even if I'm wrong once in a while, or reason for the alarm doesn't reveal itself, I'm still better off to pay attention to my instincts.

Better some sleepless night with an alive patient than sleepless nights with a dead one.