Brutal day

Thursday night I came home dejected. It was a brutal day at work and I thought, "Do I really what to do this? Can I do this?"

My preceptor has been fairly aggressive in pushing me to take on greater challenges during my orientation. Rather than follow a gentle curve of increasing difficulty—stable post-operation day 2, AV fistula, fem-pop bypass, and so on—we've been leapfrogging ahead as she feels I'm ready. Her assessment of my ability is inevitably higher than my own. She's not cruel or anything, just confident that I can handle it. She's always there when I drop the ball on details, which I do more than I like. I've been doing great with transfers out to less acute floors and stable patients so she wanted me to get more practice admitting patients fresh from surgery. On Thursday we took two empty beds and bided our time with a staff meeting and a discussion of medications.

Our first admitted patient had just undergone a carotid endarterectomy where the surgeon opens the carotid artery on one side of the neck and removes the plaque that is either narrowing the artery or is unstable and may rupture. I haven't seen it done myself, but I've been told it looks like they're scraping out chicken fat. So eat healthy and exercise! On the scale of things, it's not a big surgery. The patient had already been extubated (breathing tube removed) and was awake. I needed to assess her status, keep her blood pressure under control so she wouldn't blow the carotid sutures, and monitor her neurological status on the small chance she could have a stroke. There's other stuff too like talking to family and giving meds, but the first three are the big ones.

She's was doing well and then her urine output dropped. Almost all the patients out of surgery have a Foley catheter in that drains their bladder. It's important that we accurately record their output and after anesthesia it takes awhile for conscious control to return. We like to see at least 30 mL an hour out showing that the kidneys are being adequately supplied with blood to filter and that they are doing so. Less than that for two hours triggers a call to the doctor. In this case, doctor wanted a rapid infusion of fluid running in, what's called a bolus. Problem was that this patient's IVs were running into veins in her arms rather than a larger, central vein. Run the fluid too fast through her peripheral IV and the vein could blow. Which it did. Not really a big deal, saline running into the tissues is going to cause some localized swelling and maybe some soreness, but no serious effects. Luckily the patient had another working IV in her other arm so I switched it over and took out the blown one. These problems, low urine output then blown IV from the fluid bolus, are minor. You have to do something about them, but fairly easy to handle.

So she's mostly squared away when the next patient rolls out. This patient had multiple coronary artery bypasses and was coming out mechanically ventilates and unstable on multiple IV medications to maintain his blood pressure, heart rate, etc. I'll talk more about what a patient who's had open-heart surgery goes through in a future entry, but basically they've had their sternum cut open, heart stopped, bypasses sewn in, heart restarted, sternum closed with wire, and tubes inserted to drain fluid (or possibly air if a lung was collapsed for the surgery). Heavy duty stuff. This guy was quite unstable and had me running for hours trying to get everything done.

I don't have much experience titrating IV medications (increasing or decreasing rate of infusion to keep say, systolic blood pressure below a number set by the physician), in fact we weren't allowed to regulate them while I was in nursing school. I worry about that because while I understand what they do, all I know about dosing is "start low and go slow". The nurses at work tell me that I'll pick up what to start them at and by how much to bump them up or down. Can't come soon enough for me. Whenever this patient was starting to get out of range and my preceptor wasn't immediately available, I would be saying, "Uh, [fellow nurse] which one should I turn up and by how much or maybe I should just wait and see? Ack." Hard to detail what all happened but we had doctors seeing him about five more times for additional orders, procedures, and intense staring at monitors. Keep in mind that I still had that other patient who needed to be monitored, medications given, etc. At the end of the day, I stayed 30 minutes after just to finish all my charting—documenting my narrative of what happened and what I did about it.

Exhausted, I trudged home from the bus stop thinking, "Am I in over my head here? Maybe I should have just gone to a regular ICU."