to add to above:
1. Plastics patients when a postop heart gets osteo in their sternum and ends up getting their sternum removed and a muscle flap. Again, rare, and typically still not attended by plastics, but did technically have plastic surgery.
2. OB patients, what you said above, and add post C section septic shock. You'd think sepsis could go to MICU but they take one look at the prolonged (hours at a time sometimes) SVT with rates in the 180's-200's and turf them right to us.
In answer to your original questions:
What's your favorite thing about working in CVICU?
The autonomy. Protocols to titrate 5 pressors, sedation, pain meds. Draw labs and replete electrolytes, order blood, pace the patient. Also having the providers (residents and PA/NP staff) right on the floor 24/7. No waiting for people to page me back while I pray my patient doesn't crump in the hour it takes for a Hospitalist to call back.
What do you find most challenging?
Most of these patients are in this very fragile state where we have them sort of stable on lots of drips and therapies, but the tiniest misstep can be catastrophic. I honestly am not that bothered when patients die. I am cripplingly afraid, however, that it's going to turn out that one of my actions (of lack thereof) killed them. I know I'm not alone in saying that I go home after my patient codes or dies and run through the scenario a million times in my head, trying to pinpoint something that I could have done differently, kicking myself for not knowing some piece of patho or pharm that would've guided me in a different direction. Mind you, other RNs and doctors are at bedside in these situations and typically the patient's outcome is not directly the result of anything that I did. Letting go of that personal responsibility JUST the right amount is what's really hard for me. You can't let ruminating about work run your life, interfere with your sleep or relationships. You also can't NOT think about these incidents at all. Because that piece of patho I was missing that would've helped, you bet your butt I looked it up and I'll never forget it again. You need to be like, 4-6/10 scared of making the wrong choice, not having necessary info, because that moderate fear is what keeps you improving, it's what makes you a good nurse. Crippling fear, however, will just make you kill MORE people, so find some meditation tapes or a Xanax prescription.
What do you dislike about the CVICU?
I dislike that we are not nearly as ready to talk about futility of care, DNR/DNI/CMO, the risk/benefit of surgery and various procedures. Sure, we tell the family there's a 5% chance of death from surgery or a 10% chance of stroke or surgical site infection (I'm making these figures up, they're calculated per patient). We don't tell them that their loved one is 93 years old, and even if they beat the above odds, they're looking at months and months of rehab, pain. We don't tell them their loved one might be unable to wean from the vent, have to get trached. That they might aspirate or fail to thrive and require an NGT and then eventually a PEG tube to feed them. That they will most definitely be delirious after surgery, and should they survive, could even have PTSD about their prolonged ICU stay. We take this awesome patient, who is 'very good for 93', ambulatory, independent, oriented, but getting winded on long walks due to aortic stenosis, and we rob them of a decent quality of life and replace it with the above.
In short, just because we CAN do surgeries, procedures, therapies, etc. doesn't mean that we SHOULD. And the American public reads at a 5th grade level, so even when I am allowed to broach these topics with patients and families, getting them to truly understand what I'm saying can feel like gouging my eyeballs out with a rusty spoon.