I’ve been meaning to post this for a couple of weeks but had no energy to finish this. Finally I have been able to sit down and finish. So here it is…
There is a nurse who used to work on our unit, her name was Lisa. She comes to work PRN from time to time, and she took time to talk to me and another nurse, Melissa. Lisa was getting a patient one night from ER that was very critical and like any ICU nurse on our unit was very excited about it. We were joking around and saying how terrible we were for wishing someone harm. She stopped us and said: “Don’t think of it that way. Every day that I come to work, I pray to God that I will have an open bed or will be able to help make someone better. I will not feel bad for wishing I had a patient to make feel better.”
From that day (or night) on, when I had a patient who was stable enough to transfer, I would work on getting them out of ICU. Because I have the ability to help someone live. Every day that I have an open bed, I am excited. I am excited because I can help someone, I can learn something, I can understand something about a person. I welcome any MD or NP or PA explaining a procedure or their train of thought. Because next time I have a patient I can think ahead to what they would need and ask for and I can initiate helping someone that much faster.
Three weeks ago I had an open bed and I was the first admit. I had time to help other nurses and catch up with my patient. I got a direct admit order from a sister hospital ICU at 10:15 AM. Patient was recently discharged from a large well known and respectable hospital with a diagnosis of UTI and on oral antibiotic. She didn’t feel well so she went to a nearby hospital, our sister hospital, and got admitted to ICU. For 5 days doctors did a variety of tests to find what was wrong with her. She was steadily declining and her creatine kept going up. The nephrologist on the case decided to transfer her to our hospital because she believed she would need dialysis in a couple of days and their hospital did not have a dialysis unit. I get the report that she is on nasal canula and is responding to voice but is slightly delayed. The nephrologist started her bicarb drip at 50. Her creatinine level is not critically high yet, but the doc wants to begin dialysis in the next couple of days. The nurse stated that the patient was stable. To myself, I began to think of all the things that we would have to do when she got here. I was able to look at her chart from the other hospital and saw that she was just as stable as the nurse said. All the reports from the previous day said that she was stable for transfer. I said to myself, its ok. It will be a good admission and I will be able to help my coworkers around me. I sat around for about an hour and the patient had not arrived and cursing myself for not going to get my lunch when I got report from the other hospital, I decided to go get my lunch really quick so that I don’t have a churning stomach in front of the patient. I left a quick report with my pod buddies, letting them know I had an admission coming, but that I wanted to go get something to eat. By the time I got back up to the floor, the patient was there. I dropped my food in the break room and went inside my room. What I saw was NOT a stable patient.
There were 3 nurses, a charge and two paramedics in the room. Patient had her eyes closed and had a non-rebreather mask on. Saturation was not reading on the monitor. My coworkers hooked her up to the monitor, and blood pressure cuff, all the while I was looking at the patient. She was swollen all over and her extremities were cold and visibly blue. I call her name out and do a sternal rub, NO RESPONSE. “Ok,” I think to myself, “let’s do this.”
Vitals come up, blood pressure is in the 70/30 range and heart rate in 130′s. My co-workers are around me and we begin to think out loud. Paramedics are trying to give me a report: they got the patient on the stretcher and by the time they had her in the ambulance she stopped saturating as well on nasal cannula. They had to switch to a non-rebreather. Apparently they did not think to check her vitals. I had enough: “Show me where to sign, I got work to do.”
As my co-workers (God bless all of my ICU bad-asses) work on getting her blood pressure up (some ICU coding going on here by my coworkers), I begin to call different people:
1. Admitting: so that they could put her in the system and I could start putting orders and meds in.
2. The admitting doctor: so that he could give me orders for consults and preliminary drips like pressors.
3. Calling our ICU doc to get his butt over here and put some lines in.
I call our ICU doc and tell him what’s going on. I suggest she needs to be intubated, he asks to put her on BiPap until he gets back later. I counter with the fact that she is not responsive and that she is dropping her pressure. Could we at least get an ABG now? He agrees. Levophed ok? Yes. Whatever you need. We hang up.
I begin calling the other four doctors who were consulted, letting them know that the patient is here and critical. The nephrologist calls me back right away. I let him know our ICU doc is going to put a dialysis line in. He says that he is calling the dialysis nurse to start heading towards our unit and that we are going to do emergency dialysis. We hang up.
I turn to the patient at this time. She is on the bed, looking miserable on the non-rebreather mask. Levophed is started and is already titrated up to 15 mcg/kg/min. The BiPap machine is there, and I put the mask on, and tell the RT to stick her for an ABG. The patient is working very hard on the BiPap but she is saturating in the 90′s. My bad-ass co-workers are bringing an intubation box and an intubation med kit.
It is around 12:30 now and my charge nurse is with me in the room and we are still trying to get the patient in the system. It takes 3 calls to admitting and one call to AOS nurse to get her in the system. However, one look at her name, SURPRISE! It’s spelled incorrectly! Another call to AOS and 15 minutes later we have her in the system.
At this time the family gets up to the unit. Her daughter and the patient’s ex-husband (he’s on good terms with her, and still gives her medical advise, because SURPRISE, he’s an OB-GYN) get up to the unit. I update him (without knowing he is a doctor) let him know that we are working on getting her settled. I tell him that she is on BiPap because she was not saturating on the nasal cannula, nor on the face mask. He is asking when is she going to be dialyzed. I say, after our ICU doc gets here and places the line, and we get the dialysis nurse over here. At this time the admitting doctor gets to the room. He takes over talking to the family. I listen to what he is saying because he is also asking about her medical history which I have to chart later. After they are done, the doc leaves; family turns to me. We property introduce ourselves and they ask me to call them once the dialysis is done. They understand that we need room and space to work. The ex hands me the card with his, and his daughter’s numbers. I thank him and our ICU doctor walks into the room. He greets the ex-husband and daughter and gives a quick update on what he is going to do.
As he does so, Jake RT and I are pulling the bed out so that Dr. K could get to the head of the bed to intubate. As he tells the ex-husband goodbye, I draw up the Etomidate, and the RT is handing Dr. K the laryngoscope. I ask Dr. K if he is ready for meds and he says to go ahead and push it.
Mask comes off, laryngoscope in. With careful maneuvering he is still not able to clear the airway. We need a glidescope. Another nurse is already bringing it to the room, it is set up and Dr. K is able to intubate. Listen for breath sounds, and they are good. AC mode of 12 with 500 TV, 60% FiO2 (and titrate down to 40%) and 5 of PEEP. Dr. K drops an OG in as well and we set it to low intermittent wall suction. Airway protected.
I ask if he wants to sedate with Propofol, Dr. K agrees. He is already moving to the line cart for the supplies for the dialysis line. I call him back because someone has already set the supplies up at the table. I run to the med room and get the Propofol and get that going while Dr. K sterilizes the field and puts the mask, sterile gown and gloves on. As he is doing this, he tells Jake our RT to get an ABG in 30 minutes. I get the line kit opened and we drape the patient.
Since I recently switched from nights, there is a lot of things I have not done yet as an ICU nurse. I’ve seen them, assisted a little bit, but never actually been a primary nurse when a train wreck of a patient comes in. I had train wreck patients, just never as an admission. So certain stuff like the stuff that Dr. K needs during intubation or during line placement I didn’t know on top of my head to get, my awesome co-workers had them all ready and waiting in the room, I just had to listen to the doctor for the stuff he needed me to assist with. As he is putting the line in, he is joking around with me saying how I was so insistent on him not getting a haircut today, and I was causing all kinds of trouble today (all in very good humor, I was laughing with him, I promise), all the while telling me to get this or that.
While he is putting the line in, I keep going up on Levophed to get her blood pressure up. She is now in 90′s systolic, with Levo going in at 20 and still titrating up. For non-ICU nurses out there, Levophed constricts peripheral blood vessels causing all the blood to shunt to the heart, but causing severe cyanosis in the limbs. This patient was already cyanotic, and having Levophed up that high and still going up is not very good, but what can you do? Life over limb, so keep going. You could of course add other medications or give boluses, but other medications are also pressors or will cause the heart rate to go up even higher (just a reminder the patient’s heart rate is fluctuating between 120 and 130), so there is no need to add the same type of medication. And it’s contraindicated for her to get boluses because she is a dialysis patient and is already swollen. Albumin is another good fluid to infuse here because it’s very low volume and does cause an increase in shifting of fluid from outside of vessels to the inside, but I’ll get to when we gave her that later.
Once Dr. K is done he looks at me and tells me to not bother him ANY MORE (lol, you’re funny Dr. K) and goes out to the computer outside the room to chart. X-ray is already waiting to check line placement (it is good) and the dialysis nurse is already getting the dialysis machine prepped. As she is prepping the dialysis machine, the blood pressure is still not terrific, and the patient is unstable. But we’re hoping that the patient would be better after dialysis. Still not wanting to squeeze her arm off with the BP cuff going off in 15 minute intervals, I wonder aloud if Dr. K – who, according to another awesome nurse who came in to check on me, has not left the unit yet – could put in an arterial line in her. We go to look for him and find him on the other side of the unit, and he looks at me in a what-could-you-possibly-want-now look, I smile sheepishly and say “A-line please?”
“Maria, why?” he shakes his hands at me (guys just so you know as i’m typing this i’m laughing because this has become a constant between me and Dr. K, I’ve become that nurse that needs every possible line, and a Dr. K is the one that is left with that chore every time)
“Because I have to keep titrating her Levo, and she’s got low blood pressure, and she is about to start dialysis?” I say it as a question, because I am still a baby ICU nurse and need to make sure I’m asking for the right things.
He laughs and rolls his eyes at me and says, “Ok. I’ll put it in for YOU. Because it is you and you asked nicely. I’m going to get a femoral line in, ok?” I’m guessing he sees that I am actually trying and am very flustered.
I already have the line box in the room, the dialysis nurse is there, still prepping the machine. Dr. K starts the A-line, beautifully dresses it and everything, and tells me not to bug him any more (such a jokester).
Linda, the dialysis nurse, and I get together and go over what all has happened and what drugs that patient is currently on so that she can call Dr. L, the nephrologist, to get the orders for dialysis. He calls for 4 hours of dialysis and to go ahead and attempt to take fluid off. He tells us to hold the bicarb until after dialysis. There are also on-call orders that the nurse has, like for example lidocaine to access the graft if there is one or heparin to make sure the ports don’t clot off, or, the pertinent one in my case, albumin, because when you take a lot of vascular volume out, the blood pressure tends to tank even more, and albumin helps with that.
As Linda gets the patient hooked up, I draw up the additional labs that were ordered, swab the patient’s nose for MRSA (and pray to God that it is negative so that I don’t have to gown up and down all day) and send all those off.
I grab a chair, a Kardex, vital sign sheets and sit down in the room in front of the computer to begin to chart and fill out all the information. The other 3 consults stop by, Cardiology, Hematology/Oncology, Endocrinology, but do not give me any more orders. I spend the next hour charting my life away and catching up on her orders.
I am so grateful for the patient’s family next door because they are keeping him occupied and are being so good to me. The wife sees me on my way to the bathroom and stops me.
“Maria I know you are super busy next door, but my husband really would like a pain pill right now, do you think you could ask someone to give him one?” OH BLESS YOU DEAR PATIENT’S WIFE FOR NOT ASSUMING THAT I WILL HAVE TO GIVE THE MEDICATION, AND ACKNOWLEDGING THE FACT THAT I AM BUSY.
“I will bring it in right now,” I say forgetting about my bladder. Physical therapy has already been by, and had gotten him in bed, and I send a telepathic thank you to all the people who work with me. I give the med, check the vitals on the monitor, thank the family for being there, and run to the bathroom.
I have a couple low activity hours with my patient, Linda dialyzes her perfectly, gives 100 cc of albumin, and on top of that even taking off 700 cc of fluid, but the patient begins to decline and Linda has to stop dialysis. All in all, pretty successful first treatment.
Somewhere between 12:30 and 17:00: I wolf down my food because I am beginning to be miserable and cranky.
Around 17:00: I give my gentleman his medications and catch up on his chart.
18:00: I draw another BMP, Phos and Mag level on my lady patient. Family is in the room but do not ask a lot of questions. The ex-husband must have warned them not to pester us with too many questions and explained about all that was going on.
19:00: BOOM! DONE! OUT OF HERE! PT IS ALIVE, YOUR TURN NIGHT SHIFT.
My second day with this patient is just as busy as the first, but I’m not going to go through it now. I’m exhausted just finishing this.
But the main purpose of this post was to share my day with all y’all. The nursing students, the nurses who are considering going to a critical environment, and all y’all who are in the critical care environment. This is the type of day on which I am happy to be an ICU nurse. This is the type of day that I am thankful to have the necessary skills to keep someone alive. This is my high. This is my passion and my talent. And as much as I do, I absolutely can not do it without other people: nurses, doctors, nurse techs, respiratory therapists, physical and occupational therapists, and even the environmental services and dietitians. I respect all of you and I am thankful to all of you and I love all of you. You all make my day. You all make my patient safe.
Learning all the muscles of the hand and arm (including their attachments, their actions and neural innervations), the carpals, all the ligaments, the nerves, and the muthafuckin extensor hood in the span of about two weeks.