That 14 hr. shift I can't get out of my mind
Last week I went in for a shift at work that just stays with me.
I was "resource nurse". This is a newly created and temporary position if 2 or 3 brand new nurses are on shift. This helps lighten the load of the charge nurse who used to fill this function. I would be back up for the 3 new nurses just off graduation and orientation.
At 7pm, I sat down with the charges giving off shift report. Being in charge the previous night, I knew most of the patients. So I listened to the update and got report on the new patients; 3 from OR, 1 from an outside hospital. Here he is all happy and cute like a 5 year old is. He made me worried. One of my new nurses was assigned to him. He was on vacation with his mom from the east coast to visit family, developed a cold so mom took him to a clinic. The "flu" she was told, take him home. But, she worried and took him to another one. The " flu" some "virus"again she was told, take him home. Mom still worried. Mom's know when something is wrong; always listen to a mom. She took him to an ER. They detected poor heart function. He was transferred to us. This is why I am worried: "Viral cardiomyopathy". These kids get SICK and they get sick FAST.
So, my worried self, goes to check on my new nurses. From 8pm to 9pm I check that they have set their priorties, know their labs, understand the plan, what to watch for. I have already set my prioity; This 5 year old boy. I make sure my nurse assigned to him understands this.
By 9pm, we are escalating his IV support for his heart. His blood pressure is low and barely responding. He starts to get cranky. Mom is patient, but doesn't understand. I explain that he may not drink, and this makes him more upset. I explain to mom that the medicine in the IV stimulates his heart, and may also make him more irritable. I explain he is not feeling well and his behavior shows that. She seems relieved and at the same time anxious. Now she know why her son, who is usually happy, is not, but now understands that he is worse than when he came in.
By 10pm, we are still escalating his IV support and giving him boluses of IV fluid to maintain his blood pressure. He is still not requiring extra oxygen, but we provide him with some to ease the work of his heart. Normally, we would have put him on a ventilator and placed central lines in him by now, but his heart function is so poor that we are trying to support him without sedation. Sedation, most times, will cause a kid with poor heart function to "crash": arrest. Another post op patient in the unit is seizing and must be transported to CT Scan; the doctor on call must also go. She calls the attending to the unit so that there is a doctor in attendance while she goes to CT with the patient. It will take 2 nurses, a doctor and a respiratory therapist to transport this patient. When she returns, she we have again escalated our support and she prepares to place a central line with "conscious sedation". This means the patient will not be put to sleep, but light sedation and pain control will be given.
The line is placed by midnight and I send my nurse out for a much needed bathroom and reydration break. Ten minutes later, she is back and catches up somewhat on her documentation, while I take over care of the patient for her. The doctor ( a Fellow) and the attending both decide to place an invasive line to monitor blood pressure since the patient tolerated the conscious sedation. By 1:30 am, we have a line, but it doesn't work well. I'm monitoring blood pressure with a cuff cycling every 3 mins. with almost maximum IV heart support! This is an ICU nurse's nightmare! They keep trying and by 3:30 am, we have a functioning invasive monitoring line that gives us constant blood pressure and access to blood for labwork and a means to accurately access his ventialtion status. Amazingly, he is still only on a face mask and maintaining his oxygenation! But, his lactate level is rising fast. His lactate is indicative of his body going into anerobic metabolsm, much like an athlete during competion.
So, we elect to intubate, but not before we prepare for the possibility of ECMO. In past blogs, I've shown that excitement. Hope we don't have to go there.
The Fellow intubates in less than 2 mins. from start to finish and the little boy tolerates the procedure well. We give bicarbonate to normalize his blood pH and adjust the ventilaor. I am feeling better, more in control of the situation when we are able to take over and let his heart "rest". By now, it is 6am. The charge nurse brings me a cup of coffee and "breaks" me for a bathroom break. Ten minutes later, I sit my nurse down and tell her not to get up till her documentation is done. I have started an IV drip to control pain and another one to help him pee out the extra fluid we had to give him. I've put in a tube to measure his urine, another tube to decompress his now distended abdomen and a probe to get an internal temperature reading.
By 7am, the day shift is here and my nurse gives report while I clean up the room. We've certainly made a mess. With the room staightened up, I sit with my exhausted nurse and our coffee and we go over the documentation for the night. She has the edge on me this time. This is the second night of our new documentation software and she's had time to practice during orientation. The "mentor" becomes the "mentee". It's 9am, I tell her what a great job she's done and we congratulate each other that we have a couple days off to recuperate. We're exhausted.