Tomorrow is my last day shift, 7 am – 330 pm. It’s also my last day working with my favorite preceptor and nursing mentor, which I’m sad about. But no more waking up at 530 in the morning! I’m really never happy about having to wake up before 8 am.
January at work has had it’s ups and downs. Some days I feel really on top of it, and others I really struggle. Overall I’m astounded how far I have come in the past 6 months. Yesterday one of the Doctors at work updated me on the health of an extremely sick patient we cared for a month ago. This particular guy came in by private vehicle with his family who suspected he had overdosed. He was in his mid-twenties and nearly obtunded, unable to communicate, a stare that went right past you. The next three hours were are clear demonstration of a phrase I had often heard but never experienced- what it means to have a patient ‘crump’ on you. Let me try to explain what a wild ride it was…
First of all, getting this sick patient undressed, into a gown, and taking his vital signs was no small feat. Someone who does not understand what is happening or how sick they are is usually more of a hinderance than a help. I will spare the gory details. He was a direct back from triage, meaning we had little to no information on him (usually triage collects an initial set of vitals and a more complete history, which at least gives us an idea of what we are dealing with). He was at that moment a complete unknown. Initial vitals were fairly stable- blood pressure was low around 100, but nothing to call the Dr. in for yet. So we get an IV, try some Narcan to reverse CNS depressants, and nothing. I get a bad feeling at this point and decide to get his blood pressure again (last one was about 20 minutes ago). This time his pressure is in the 80′s (anything less than 80, and we know the brain isn’t being perfused enough, and therefore isn’t getting enough oxygen. This is bad). Then his oxygen saturation drops into the 70′s every time he removes his supplemental oxygen. This guy is really sick. I call the Dr. back in, and my preceptor comes into the room and tells me we need to switch him to one of our critical rooms.
The next few hours are non-stop. First, airway has to be stabilized. He isn’t oxygenating properly, and his level of consciousness is severely diminished. We have to intubate and quickly. While one nurse works on starting a second IV (which is no small task- his pressure is low and he’s so sick that his veins blow quickly) I crack open the rapid sequence intubation box (full of all the drugs you need to sedate and paralyze someone) and draw up the drugs ordered by the Dr. Let me pause for a moment and try to describe how nerve wracking this small task is for a new nurse: I have a box with 6-8 different drugs in different vials. I get a verbal order to draw up x mg of this drug and x mg of this drug. I have to pull up the appropriate amount of each drug (which requires some quick and simple math), and push them in the correct order (can you imagine being paralyzed before you are sedated? Not fun). Meanwhile, there is a patient trying to die on the table, a Dr. at the head of the patient standing with intubation equipment at the ready, and a respiratory therapist at assist with the mechanical ventilator prepared to breath for the patient. And then there is me, a 6 month old nurse, with powerful drugs in a syringe that will incapacitate the patient. It is quiet a rush, let me tell you. Meanwhile we are dumping fluids into the guy as fast as possible, hanging a few different antibiotics, monitoring all of his vital signs, trying to establish appropriate IV access, and facilitating the many interventions that have to take place on an interdisciplinary level (lab work, EKG, chest x-ray at the bedside, then to CT scan). This is all non-stop, one thing after the other. Even getting him to CT scan is a feat- it takes 3 people to wheel the gurney (which has to be navigated around doorways, medical equipment, other patients, and medical staff), IV pole (which has 4-6 different drips and fluids on it and can’t stray far from the best lest we rip our life-saving IV’s from his arm), and mechanical ventilator, which has a few feet of slack between the machine and the tube that is strapped into his mouth and breathing for him. All of these things are vital, and yet we must move quickly. The last thing you want is for your patient to code in the hallway, or at CT scan.
Once he is stabilized and all of the preliminary imaging has been completed there are a few more tasks to complete. Drugs that we have hung to keep him sedated must be titrated, per nurse discretion, to obtain the appropriate level of sedation. Too much sedation and his blood pressure will dump. Too little, he will wake up and rip his lines and / or breathing tube out. It’s a fine balancing act. Meanwhile, we must insert a tube through his nose into his stomach to decompress the stomach. We have to insert a foley catheter to monitor his urine output- this gives us information about his kidney function and fluid status. The foley also measures his temperature, which ends up being over 104 F. A temperature this high will cook your brain. We put ice packs at his armpits and groin to try and cool him down. Meanwhile, his blood pressure continues to be extremely labile, and we struggle with sedation. He becomes agitated at points and tries to reach for his tube. His pressures oscillate between normal (110′s) to life-threatening (70′s and 80′s). My preceptor orders another drug which will constrict his vessels and raise his blood pressure. Whenever we need something ordered by the Dr, or when shit hits the fan, we have to rush around and find the Dr. / respiratory therapist. Also at the bedside- some of the family, and multiple admitting Drs, specialist, etc. And while all of this is happening, I have to be charting. I end up pulling a few paper towels down and writing brief timed notes so I can go back later. At the end of the night I sit down and transcribe 6 sheets of paper towels onto our nursing flow sheets.
We finally get him up the the ICU, alive if not totally stable. The Dr. tells me as he leaves for the evening, “good job today. That guy was really sick.” It was a good feeling. I have thought about him frequently over the past month. The Dr. informed me yesterday that our patient was extubated the other day and discharged to home. He was experiencing septic shock (an infection in the bloodstream). During his hospital stay he suffered from heart failure, liver failure, and kidney failure. While I don’t know the details of his outcome, I know he is alive. It felt wonderful to know at least that- so often we get our patients up to the floor of ICU and never find out what happens to them after that.
So you know- just another day at work. This is one of the things that make it work it. The exhilaration of dealing with the complete unknown in life or death situations. The ability to look at an extremely sick patient in front of you, anticipate what needs to be done to save this persons life, and completing those tasks. And NOTHING ever goes totally as planned. You have to roll with the punches, you have to adapt, change your plan. You have to be ruthless at times, advocate for your patient, make sure that appropriate care is being given, making sure the people that need to be in that room at a particular moment are there. You have to know when to get the Dr. in there, and when to handle it on your own. You have to know when to ask for help. While all of this is happening, I have another patient. That’s another thing I love about the ED- fantastic teamwork. You have to know your team has your back. No one can do it on their own.
And with that, I should go continue to enjoy my day off. Tomorrow will undoubtably bring another wild ride, and I need to be well rested!
