Saturday, March 2, 2013

Live blogging on super sick patient

Background: Middle aged female, arrested during routine dental procedure. Cause unknown. Arrested twice more since admission to hospital. Lactate trending down, now at 10. pH finally normalized to 7.34 overnight. Complete heartblock resolved now to sinus tach. Mediocre urine output, creatinine of 2.3. Troponin of 20.0. Fever of 40.3 (that's 103.5 for farenheit users). Drips: Versed, Fentanyl, Insulin, Bicarb, Epinephrine, Phenylephrine (maxed), cisatracurium, heparin.

0800

Nephrology team: Intern freaks out because of fan blowing on patient under sheet "wind tunnel" for fever. "How can I assess the patient?!" he asks frantically. Step 1. Turn off fan. Step 2. Pull down sheet. Step 3. Assess patient. Wow, this is so difficult.

Nephrology team again: Snarky comment, "ok all powerful ICU nurse, we are going to put a triple lumen on one side and a double on the other". Well gee, don't work too hard on my account. As if it's my fault the patient needs that many lines!

0900

Pulmonary fellow splatters blood on my bed, and almost on me. I love my pulmonary fellow. I shout, "hey hey, you're spraying blood everywhere!" Fellow to me, "Oh shaddup." Intern staring. Fellow to intern: "We've worked together a long time."

Same fellow shouts of the room: "Can we get her a hairnet? I mean, a bonnet?" Do we call them hairnets? Or bonnets? What do we call these surgical caps anyway??? Hairnet and bonnet just sounds weird...

Coming down on Phenyl. All other drips the same. I'm about to send a gas, see what we can do with her vent settings (80%, 40/18 pressure control). Also, thinking about setting up the filter (CRRT) now. Man, I set these damn things up a lot.

Oh, and I had a red bull this morning but... is there coffee around here anywhere???

1000

Made a coffee run. Also got a stellar blood gas... 70% here we come, also weaning nitric oxide down now. Did I mention she was on that?

And to whoever put the donuts in the break room... I HATE YOU!

1100

Where is the time going?? Pulm fellow made a mess in my bed, as in blood. So we got to change her sheets and give her a bath. She didn't like bathtime... BP bottomed out, and she got extra of epi and phenyl. Boy does she need that epi. The second it beeps that it's out, I have to go running and change the bag lickety-split, or she's out of BP commission for the next several minutes.

Making more improvement in vent settings. Yay for that.

1200

Spent a lot of time talking with the family, explaining everything. I actually like that part of my job. Family is super nice. Coming down ever so slightly on phenyl. Vent settings look good. Off nitric soon?

Sidenote: I'm wearing my new glasses today. So spiffy.

1300

Dopplers, and EDMs, still give me a panicky feeling. PTSD from losing the baby.

Ta da! Renal has shown up to finally put in the sorensen. A million hours later.

This renal "fellow" frightens me when he's in the room alone with my patient. He's not the brightest bulb in the box... he totally makes me nervous in there alone.

1400

Wow this guy just had me go get him all his items. The Renal folks are usually so independent, and get their own stuff. I just hope he knows what to do with it.

1800

Just spent the last 4 hours messing with a filter. Setting a new one up, watching it work for 15 minutes, spending an hour (almost) trouble shooting very high pressures, finally giving up, tearing it down. It was a four hour exercise in futility, actually. Luckily, patient's urine output really picked up and her electrolytes are ok without dialysis. Stay the course.

Good news on vent settings: down to 50% and 36/14, nitric at 2. Much less febrile (38.4). Way down on phenyl requirements. So all in all, good work. A lot of extra work, but the patient didn't suffer for it so I guess that's all that matters.

Why can she not have a dialysis cath anywhere but her fem sites? Because NO WIRE can go into her atrium. It puts her into PEA arrest every time, due to her LBB. Interesting.

I'm tired. Haven't peed or eaten since this AM's coffee run. Need to SOAP on this patient and do her care plans. Meet my carpool rider and get my butt home.

Hope you enjoyed this lovely day in the life of an ICU nurse post!

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