Thursday, April 22, 2010

4th day ICU

I feel like I've learned so much more in the last 4 days than I have in a year on cardio-thoracic surgery. Today my patient from yesterday was doing worse than before, in every way. My preceptor left me alone for 5 minutes, and of course the patient's BP went from 105 systolic to 60. I got another nurse to help but told him to NEVER leave me alone again! All we did was bolus him fast but it all leaks out of his vascular system as quick as we could put it in. I mixed up levophed for the first time, just in case, but we didn't need it. I've never mixed up an IV med before.

I also did all of the charting and meds and organization of the day. The family was distraught because basically their dad/husband is going to die, and everything we're doing is just prolonging the fact. A half hour before I left, I checked a residual on the NG tube and got back blood. So we set up and did a gastric lavage. Oh, and nurses also place the dophoff tubes. So take that all you cardio-thoracic PAs who think you're so hot that no one else can drop a tube!

Tuesday, April 20, 2010

Toto, we're not in surgery anymore

Cardio-thoracic: The doctor tells a PA what order to write. The PA writes it, and the patient asks the nurse "why?". The nurse asks the PA "why?" and the PA either ignores the question or rolls their eyes and says they're busy.

CCMU: The doctor makes a suggestion for plan of care. The nurse says "I don't that will work because...", the doctor says "oh yeah, that's true", the resident writes orders according to what the nurse dictates.

Cardio-thoracic: You need stat labs. STAT usually means between 1-2 hours, even though you've paged the floor phlebotomist, and the charge phlebotomist twice. You try to find someone on the floor who actually knows how to stick a patient. Respiratory therapy ends up taking pity on you and trying to help you.

CCMU: You need stat labs. You go to the draw, take out the syringe and tubes, and draw the labs from the art line. The respiratory therapist says, hey will you grab some blood gases too? And you do. Then you print the label, walk 8 steps to the lab, and drop the labeled tubes in their bucket. They hand deliver the results to you 10 minutes later.

Cardio-thoracic: The doctor's name is "Dr. P." In two years, he has not made eye contact with you, addressed you in any way, and ignores any comment you might deign to make in his presence. When he walks down the hall, you are expected to move immediately out of his way, or risk the withering glares and cold shoulders of his PAs for the rest of the week.

CCMU: The doctor's name is "Jack". He sits at the desk with the nurses, making chit chat. He shakes the new orientee's hand and introduces himself. He asks the bedside nurse if she agrees with his plan. He is grateful for her input, even though she is directly contradicting him. He remarks on the high acuity of a patient given to the new orientee. He seems, um... human.

Monday, April 19, 2010

first day in the ICU

I was given a room number and a time. I showed up in scrubs, with my chai tea latte, looked around and thought "why do none of these other people look like orientees?" OMG, they were all the staff nurses and we were doing report! This guy says "hey you're with me today" and then next thing I know I'm signed up for bed 4. There's my name, next to the patient's name, as IF I have one single clue what I'm supposed to do! I thought, well, it's time to just get up and walk out of here because I have made a BIG mistake and I'm not about to kill a patient today!

Luckily, the nurse educator happened to be staffing, so he sort of showed me some stuff, intro'd me to the unit, made me do some competencies online, introduced me to people, and I went to a staff meeting on sentinel events (which included pizza). Basically, all I learned to do was draw blood off an art line, and even that I managed to screw up the second time.

Vents? Totally puzzling to me. 8 pumps with 8 meds that have to be juggled, if one goes up the other goes down, how will I ever remember that??? CVP pressures, why are we doing this again? Oh god, what have I gotten into. I feel like I never went to nursing school for a day. I'm totally lost.

Tuesday, April 6, 2010

countdown to ICU continues

My last few weeks on the only floor I've ever known as a nurse have not gone well. I have had one big confrontation with a busy-body co-worker, and 90% of the rest of the nurses pretend I don't exist.

For example, Saturday I took a post-op day 1 esophagectomy patient, whose attending happens to be my very favorite. I started at 3 with a dismal report- very low urine output, even after 1000ccs of bolus and maintenance fluid at 125 cc/hr. BPs super low, pain super high but couldn't do much because of the low BPs. Patient couldn't get out of bed as she was suppose to, and lungs sounds were crappy. I took the patient hoping it would be a challenge that might help prepare me a little for the ICU.

I was managing alright, even got the BPs to stabilize and the PCA and epidural back on, getting her pain down from 10/10 to 6/10. The family liked me and felt confident in me enough to go home for the night. I spent almost every second of my shift at her bedside, only dashing in and out of my two other (stable) patients' rooms, or delegating their meds to the two other nurses who were actually offering me help.

At about 8pm, respiratory showed up to do a breathing treatment. I'd been playing around with the pulse ox for about 45 minutes, warming up her hands, trying her ears, toes, etc. Respiratory tried to help me, and finally got an ok reading, 92% on 3L nasal cannula. BUT- in the process she went from A&O x3 to A&O x1. I was like, oh shit... what is happening??? Urine output for four hours was 25ccs. Resident on call wanted to bolus her AGAIN. I regret not saying NO way. I regret not turning all of her damn fluids off right then.

Suddenly, her sats started dropping. I stat paged respiratory. I told my charge and assistant charge nurse that I would need help with a driveline and meds because I could see this was not going to be good, and I got a great rolling of eyes from them and nothing but reluctance, so I just left. I was stat paging phlebotomy now for labs, and they weren't showing up. Respiratory and pain service were my only help at this point, and they started drawing ABGs and said they'd fill my other tubes for labs.

Now you have to realize, I've never drawn labs in my LIFE! I again went to the charge nurse, asked her for help, she refused, and I said "should I call RRT? (rapid response team" (Resident on call STILL wasn't there, patient now on a rebreather with 100% O2). She says "Call RRT just for labs?" as if it were the stupidest question ever. I went back to respiratory, the supervisor was now there, and said "should I call RRT?" I'd paged the resident on call about a hundred times by now, respiratory said to call RRT, so I paged him one more time and said "If you can't make it now, I'll get RRT".

Guess what? He shows up one hour and 45 minutes after the crisis began, and said "Bed 14, nurse Michelle, call report." I went to the charge nurse and said "She's going to the unit". Her snotty response? "What? I can't even understand you." The other nurses around were listening now. I said, very slowly: My. Patient. Is. Going. To. The. Unit. Did you get that? Because our charge and ass charge didn't step foot in that room the entire time, and I never felt so on my own before.

Grrrr. Now my patient is on a vent with major hypervolemia. Her daughter saw me and hugged me and told me thank you, thank you but I felt like a fraud because I wish I had turned off the fluids. I left the unit with tears in my eyes.