What is JET?

Junctional Ectopic Tachycardia is a post-op arrhythmia caused by trauma to the conduction system around the AV node, usually appearing within the first day after surgery.  

A narrow complex tachycardia, usually 170-260 bpm, hemodynamic instability can occur due to the loss of AV synchrony. Tetralogy of Fallot, VSD, complete AV canal, and other RV outflow tract defects, as well as long bypass times, are associated with JET.

So your patient has gone into JET. Now what?!

• Check blood pressure and make sure they are maintaining it.

• Check and optimize electrolytes (especially mag).

• Pace to restore AV synchrony. Initially atrially pace at 5-10 beats above the heart rate (“over-drive” pacing), then at a slower rate when tachycardia reduces. Stop frequently to evaluate underlying rhythm and rate. 

• Implement cooling measures to decrease heart rate and improve cardiac output (~ 35 C).

• Minimize positive inotropes (especially Epinephrine and Dobutamine. Milrinone is the inotrope of choice because it does not raise the heart rate).

• Give Dexmedetomidine (depresses AV node, can restore sinus rhythm).

• Give Amniodarone if unstable (slowly to reduce the risk of cardiac arrest).

• ECMO and ablation in resistant JET.

9 Stones

There is a time, a time to love
A time to sing, a time to shine
A time to leave, a time to stay
There is a time, a time to cry
A time to love, a time to live
There is a time, a time to sing
A time to love

~Mumford & Sons

It was bound to happen. Especially to me.  I verbally process everything and take things personally. Too personally.  

I was bound to end up in counseling.  

It was good.  The lady sitting opposite of me didn’t know me at all. She didn’t know my work.  Had no idea what kind of nurse I am.  She didn’t know what happened every single day at work. She didn’t know I was a senior nurse with more experience than 70% of the nurses I work with.

She asked me how long I had been an ICU nurse and she jerked back to look at me in surprise when I said quietly “Almost 7 years.”  

I knew she was expecting me to have been a nurse barely a year or maybe just at a year.  Surely someone who was 7 years into this sort of career knew what to do and how to survive.  

I always thought I did. I used to bury myself in soccer and sports.  Then I got married and buried myself in that.  Turns out my husband doesn’t want to hear about my day every day.  So I stopped talking about it.  I stopped finding a way to get rid of the mountain of stress that I acquired every time I worked.  It built up.  Until one day when the doctors didn’t listen to me and the patient died- the guilt of thinking I should have done more overwhelmed me.  I stopped sleeping well before shifts.  I would toss and turn half the night.  I turned to sleeping aids.  I would wake up before my alarm and lay there with my eyes wide, dreading the shift.  I would walk into a room with 6.5 years of experience on my shoulders and feel a desperate terror that I had no idea what I was doing.  I would be filled with anxiety and be unsettled.  They gave me an orientee and I panicked.  I couldn’t do it.  I felt overwhelmed and terrified. I took the nurse educator aside and begged to have the orientee switched.  I told her I couldn’t do it and was burnt out.  I told her I was in counseling and needed to get myself straightened out. I was brutally honest and felt a measure of shame that I was so broken.

The counselor listened to me and asked questions here and there.  I cried for a half an hour the first session.  She gave me some tips for coping with the amount of death and suffering I see every shift. She told me to put stones in a jar to memorialize each life that I lost or that was lost when I was there.  So far I have 9 stones.  I actually thought there would be more.  And then I realized that 9 stones is absolutely insane.  Normal people don’t encounter 9 deaths in their lifetime- let alone in a month and a half.  Healthcare personnel deal with death so regularly that 9 sounds like a small number.  But that is 9 families that have lost a loved one.  9 people whose lives have ended.  9 people who I either held their hand or broke their ribs during their final moments.  And, I know the number will climb.  That jar will be filled.  

The counselor talked to me about PTSD and told me that people in healthcare get overlooked.  She said that firemen, rescue workers, nurses, doctors are just as susceptible to PTSD as soldiers.  It’s a different horror- but it is horror just the same.  As she spoke and validated the devastation my soul had been feeling… I felt a small part of me heal.  I wasn’t crazy.  I wasn’t weak.  I was a 31year old nurse whose eyes had seen too much.   I don’t know how many counseling sessions I will go to.  Whether the ones I have had so far will be enough to really help me cope.

I just know that I can’t save lives if I don’t first save my own.