Another night in the salt mines

By LA-jan - January 09, 2015

It is 7 pm.
"Janet's your Charge nurse tonight"

Wha. . . ,  oh someone must have called in sick, I think
and up I jump up from my seat in the huddle room and carry my backpack
and water bottle to the nurse's station
to greet the off going Charge nurse.

"Am I glad to see you", she greets me, and off we go the the report room
for a report of the day.
"I had 4 sick calls and 7 admissions! "
"Sorry, but I had to put you in Charge".
No problem, I say.
16 patients on the unit, 1 still to come in, 4 surgeries tomorrow, not including
the sternal closure on one post-op to be done at the bedside.
One ECMO on the unit that just came back from the OR and
has been bleeding profusely , one of the ORs is a patient on the unit
that has been having cyanotic spells all day, one patient just finished
a delayed sternal closure at the bedside and few others
with a miscellaneous bag of ills.
It'll all settle down, I think, we got this.
My second in command, or Resource nurse, is an ECMO trained
efficient one with a quick sense of humor and is highly
independent, as she should be. My Fellow on call is
calm, easy and efficient.
Even our UA (unit assistants) are fun and easy with a joke but all business and highly efficient
when the need comes.
It will be a good night, alright.

OK, a little levity here.

Emergency checks, check with my Resource that breaks will work out and then
figure out staffing for tomorrow, check surgery and cath lab schedules,
a quick update from the Fellow and down to huddle with the rest
of the hospital's charges with the House Supervisor.
I'll let them know my census, my bed availability, expected admits, surgeries, and
transfers. Then, I'll let them know I am short-staffed in the morning.
PICU wants to send me an ECMO nurse, but I'll have to replace her.
NICU is right on, with no nurses to spare.
My step down unit can take my transfers. As a matter of fact, they need
patients and want one ASAP! Good news!
I head back to the unit and let my Fellow know we can transfer one patient out tonight.
I call the nurse in charge of that patient and my Resource to make it happen within the hour.
Then, I round. Check in with each nurse to see how things are going,
trouble shoot problems, take notes on changes, make suggestions for
the newbies. 
The ECMO room needs breaks after they draw their labs. They are almost done,
I'll be back in a few minutes.
Then, I hear "Janet, we need some help here!" The ECMO alarm is sounding
and I rush in. The pump stopped, I check the pressures. We have a clot!
I look at the oxygenator and it is clotted black!
We have to come off ECMO. Clamp, open the bridge and support the patient
while we trouble shoot, call perfusionist, grab a new oxygenator, a new ECMO circuit,
call the Fellow simultaneously while making sure the blood bank and OR are called.
The Attending shows up, the kid is doing fine, thank goodness!
The clot moved, now circuit is moving off the patient, but the clot is ???
We've got to move fast, the cannulas connected to the patient will clot.
We're stuck between a rock and a rock.

It seems longer than it takes, but the perfusionist and surgeon, (who was in the shower)
show up and calls are made, the decision to check the cannulas is made, a new circuit is
primed, the cannulas are bleeding!! We can connect the new circuit!
Back on we go and replace lost blood to the patient and a big relief is felt by all.
Parents are updated and clean up is done.
It is time to round with the Fellow. We get to the first patient and we get a call, that the
new patient has arrived on the other end of the unit.
We abort rounds and head to see the new patient. All the while the Fellow
answers calls from the nurses: BP dropping, titrating medication drips, giving
volume, checking labs. Fortunately, the new patient is just as cute as a button, here for obsevation
and possible work up for surgery,
and just upset that we've held off her feedings for the ride over.
We continue with rounds.
It goes well, we catch up.
I call the step down to let her know we'll have 2 more patients to send her in the
I call staffing to let them know of sick calls and low staffing,
census and acuity numbers.
Time for a break! It is now 2:30 in the morning.
I get back from break and I hear there is a patient in the NICU, just arrived
with incorrect diagnosis and now has been identified as a heart patient and
needs emergent intervention as the baby is rapidly deteriorating.
I move a patient, to free up a nurse for the admit.
They call back. We are cleaning the room, the cardiologist is going to take
the baby to the cath lab I told her.
Then I find out, no time, the cardiologist is doing the procedure bedside, in
the NICU.
By 5:00, procedure done, they call. Are we ready?
Yes, send the patient.
It'll take a while, they say, so much equipment.
They arrive at 7 am.
Next shift. Time for me to give report  to a new, fresh Charge nurse and
her Resource and Situational Awareness to the oncoming team.

And I'm out by 8.

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