Sometimes it’s the smallest things that make the biggest difference in a patient’s care. I had a new patient in the observation room, with a very common story. A teenager in a car accident, unrestrained, with a high blood alcohol level. He suffered a closed head injury, a suspected neck injury, fractured pelvis, broken ribs, arm, foot, and had been in ICU for 2 weeks. For almost all of that time he had been on a ventilator, and had to be feed by a feeding tube. My report was that he was awake at times, but not participating, he rarely followed commands. He had wrist restraints and a vest restraint, he had been pulling at his Miami J collar, tracheostomy, PICC, and feeding tubes, morphine helped to make him less restless. A seventeen year old should not be in a place like this, but I had seen this happen to quite a few. I did my assessment, I asked yes and no questions and got no reply, I asked him to move his legs and only got a frightened stare in return. He did however; follow me with his eyes, the whole time I was at his bedside. There was something going on in his head, but he wasn’t letting anyone know what it was. My patient had physical & occupational therapies working with him, but all their notes stated he was not participating, they would check back when he was more alert. I struck out on all my attempts to communicate with him, but I felt there must be some way, so I went to my lead nurse Liz. Liz is probably one of the smartest nurses I know, her assessment skills are excellent and knowledge base is invaluable, she’s my go to person. She put her work aside and came in, and took a look. After her assessment, she agreed with me, there was someone in there, and we needed to find a way to communicate with him. Off came the restraints and into a geri chair went my patient, he began to seem a little more engaged. He began using his hands to feel around, touching the tubes, not pulling. There was a stuffed animal by his bed from his Grandmother, Liz picked it up and tossed it at him, he threw it back. We had him now, he was interacting. Then, with the simplest of ideas, Liz got him a clip board, a piece of paper, and a pencil, and asked him to write his name. He didn’t. Liz wrote on the paper, What is your Name? he wrote his name, and lots more. Not all of it made sense, but he was able to make his needs known. The look on his Grandmother’s face when he wrote to her was gratifying. He began to work with PT and OT, and we were able to get him to a rehab facility in the city, within a week or so. It’s the small things that matter, Liz stopped what she was doing to look at my patient, she spent time with him and me, and came up with a solution. Because of this communication solution, my patient was able to interact with staff, participate in his care, and get to rehab more quickly, always a plus with brain injuries. Liz is an invaluable go to person, I depend on her excellent assessment and decision making skills, but above all it is her compassion that makes her an Extraordinary Nurse.