How was your 4th?

By LA-jan - July 06, 2013

Fireworks,  bbq hotdogs, apple pie?
We were scattered, each celebrating in our own corners.
Terry was home watching fireworks from the front
porch (compliments to LA Dodger's home game), while
Taylor took off to celebrate with friends.
I went off to work, after missing the night off
due to unusually high census.
Not without fireworks, though!
Started out my shift with code blue at 5 min. to eight, just after
finishing report from the day shift charge nurse.
I was night shift charge nurse tonight.

Off to follow the code lights to find
the little post op infant whose struggle with
pulmonary high blood pressure got the best
of her. In no time, compressions were started, a dose of epinephrine
to jump start her heart and vecuronium to paralyze her struggle,
we took over with manual ventilation, a little volume
and we were good. Move on.
I got a call on my polycom from the other end of the unit.
Baby struggling with increased work of breathing.

In no time, the baby was intubated and place on the ventilator.
Before 9pm, I still have time to make "huddle"!
 Huddle is a discussion downstairs by all the charge
nurses of all the units with the nursing supervisor of
the hospital to go over census, expected admits, ORs
discharges and transfers.
Oh, and that important issue, STAFFING!
Yes, I'm short nurses, my census and acuity is high!
We will make it tonight, but am shift will need help.
We have 3, maybe 4 ORs tomorrow!
I am optimistic. ER and PICU are not busy, and
are actually over staffed tomorrow, if the night
holds, there is hope!
I return to the unit to make my rounds to check for trouble spots,
both with the patients and the nurses.
I have a new nurse and the end of the unit with a busy pair.
I've sent my team leader to stay close with assistance, as
the newly intubated patient may need her help too and is
I start on the other end.

 First part of the unit seems to be in good shape.
I move on.
We have an unexpected admit from day shift that was rushed
to surgery. A newborn, well, 4 days old, with an undiagnosed cardiac defect.
Until today, when the proverbial "s#@* hit the fan".
Now, post-op, the baby is oozy. Blood transfusions, platelet transfusions
are in the works, inotropes titrated with blood pressure responding.
My nurse has it all under control.
I move on.
Next, the baby we waited all night the previous night for from Guam.
The baby started it's journey on Sunday with out transport team in Guam.
On its way in the airplane over the Pacific, things went down hill fast
and the plane was ordered to land in Hawaii by the physician.
This baby needed a septostomy. And fast!
Fortunately, there was a cardiologist in Honolulu who could provide
that. He was able to thread a small cannula with a balloon, into the heart, thread
it through the upper chambers and inflate the balloon to rip it back through the
wall to make a bigger hole. This would provide blood to be oxygenated better,
as the defect without this "shunt" would not support life.
By Wednesday evening, we received word that this transport team, still in Hawaii,
was leaving with the baby to arrive early the next morning at 3am.
Enroute, I received a call from the access center, that the team had coded the baby
twice over the Pacific and that things were dire. No communication was
possible. We had to prepare for all case scenarios.
Cardiologist was called in. What is the septostomy failed? It would have
to be done on arrival at the bedside.
What if the baby needed ECMO? I made a plan with the team we had on hand.
Assignments would have to change. The surgeon on call
was notified. She was in the OR at our sister hospital in the middle
of a heart transplant! Well, we had a few hours still.
The baby arrived with the ragged transport team
enroute since Sunday, now Thursday morning,
and none of the scenarios played out, fortunately.
Equipment malfunction was fixed and all was not dire!
This baby was not a worry now. Sick, but my nurse was OK!
Move on.
I passed a parade by one of our pretransplant patients (waiting for a heart) 
with his family in tow.
Brother was passing out glow sticks and balloons he had made with
gloves for all the staff! Our 4th of July celebration!
Armed with my glowstick and balloon, I moved on!
A couple more post-ops, one arrythmia intervention,
a pre-op for the following day, another pre-transplant crying with her nightly
bath ritual, the teenager in bigemeny again

Is his blood pressure stable, I asked one of our newer nurses? Any more vomiting?
Did we check his electrolytes? Sounds like he's handling it ok, move on.

I'm making it down to the end, the pair with the new nurse is fine, a pre-op next,
but the newly intubated baby is still struggling. The tube is too small and there is a
leak of air around the tube that is impairing our efforts to ventilate.
We need to re-intubate with a cuffed tube. Meds, sedation, and volume all
at the ready. I record for the nurse as the new tube is inserted.
The procedure goes well.
I look up through the large windows in this room above the computer,
and what a panorama! It looks out over the city and
I see three firework displays going off simultaneously!
Can we turn the lights off guys! Look what we are missing!
And it is not even 11pm!
 Hope your 4th was just as exciting!

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