Tuesday, April 07, 2009

This night, that night

Another dichotomous pair of nights a little while back. The first was the easiest night at work I've ever experienced. Came in at 6:30 PM to find out we were overstaffed and it was my turn to float to another ICU along with a few others. The ICU supervisor changed her mind at the last minute and kept me on my home unit, but by that time everyone was assigned and so I had no patients. I'm decidedly not a "whoo-hoo, extra break time!" kind of person, so I helped out all over the unit with transfers out, completing paperwork, and helping bathe patients.

When it was close to 11 PM, we were still overstaffed, in part due to the transfers with which I helped, so I floated to a medical ICU upstairs. Though we're all ICUs, the ones upstairs from my cardiovascular surgical recovery unit are arranged differently both physically and in terms of workflow. They use some computer charting that we don't, supplies are stored in different places, medications available on the unit are slightly different, etc. Thankfully, the med ICU staff observed both common sense and policy in giving me a fairly simple pair of patients. When floating to such a different environment, this is the way it's supposed to happen. Just as we would never assign a fresh surgical patient to a float to our unit, they're not supposed to assign us just-admitted patients or unstable ones because we aren't familiar with the lay of the land.

Both my assigned patients were doing fine. One was due for transfer out of the ICU to a regular acute care floor, there just weren't any beds available. His big issue was very high blood pressure, we're talking 200/120 (normal is less than 120/80), which kept surprising me for the first few hours. Though his status only warranted charting blood pressure every four hours, out of ICU habit I still recorded it hourly. When I'd peak in to read his BP off the monitor, seeing 190/100 or somesuch kept making my brain go, "Too high, ack! Must take action! Assess patient, medication, notify doctor!" In reality, he'd been living with blood pressure this high for awhile and rapidly bringing it down would put him at risk for a stroke. The plan of care was slow reductions through careful increases in his medications. As the night progressed and he slept soundly, the pressure came down nicely.

The other patient was a lovely lady who's heart arrythmia caused fainting spells (syncopal episodes) at home. With medications administered at the hospital, that arrythmia was now under control and she would probably be transferred to the floor the next day or even discharged home. We had a few nice conversations and I reinforced some of her health teaching. It was such a slow night that I finished all of my online education modules that aren't due till October and tried, mostly in vain, to help out the other nurses on the unit. A couple of them joked (semi-seriously) that I was so willingly helpful that I should transfer to their unit permanently. A nice compliment, but also a necessary trait on my home unit. Easy, easy night.

Just a couple nights later I was back "home" working with another nurse in caring for an unstable patient. Blood pressure propped up with several continuous IV medications, multiple blood products needed, an air leak in one lung causing massive accumulation of air under the skin, no neurological response to painful stimuli hours after surgery - very sick patient. The air leak was the most immediate striking. Because his lung wasn't completely sealed like in a normal person, every "breath" delivered by the ventilator caused some air to leak into the body cavity resulting in subcutaneous emphysema. Chest tubes inserted in his chest were helping drain fluid and air, but couldn't keep up. So air accumulated in the chest, then made it's way down the arms and up the neck to his face.

When there's a little accumulation, you can feel and hear air bubbles popping under the skin. It's called crepitus and it feels (and sometimes sounds like) Rice Krispies. In this patient, the accumulation was so great that his skin bulged out and sounded resonant like a drum when percussed. Warning to the especially squeamish, there's no blood but maybe you don't want to see this (not our patients BTW). His chest x-ray was incredible. Because of all that air, you could see the striation pattern in the pectoral muscles, something that won't turn out on a normal x-ray.

He didn't look good, but subcutaneous air isn't especially dangerous in and of itself. More important was the blood pressure and the fact that he wasn't waking up. We had orders to paralyze him with medications, but we never started them because he wasn't moving around at all, even to painful stimulation.

As I explained here, when we're working as a two-nurse-to-one-patient team, one person does the charting and directs the team, the other person performs the physical work. I took the physical role this time. It worked out well, because she needed to sit down for most of the night and my brain wasn't running 100% due to poor sleep the day before. I'm pretty well-known for being let's say energetic at work. This night, around 4 AM, I walked past our charge nurse and she pulled a double-take. "I've never seen you look so worn out. What's that patient doing to you?" she half-joked. It was true, except for a 30 minute lunch, I didn't sit down the entire night.

At one point, the patient's heart converted to an arhythmic condition which impacted his blood pressure. We gave an arythmia medication to try to break him out, but it didn't work. We moved on to synchronized cardioversion where we attempt to shock the heart back into a regular rhythm, but that too failed. Still, we kept the blood pressure up, the pulses intact, and the oxygenation status good. In the morning, the attending physician - a notoriously critical doc - actually told me and my partner nurse, "Good job." Could have knocked us over with a feather.

That's how it goes at work. Sometimes you have an easy night and sometimes you get beaten up.

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