armyicurn, BSN 4,256 Views
HI, got questions? Just ask. :)
Just sharing an ECMO article I wrote. Cheers!
I am an ECMO nurse. I work with a machine that helps patients who have 80% chance of dying. In a critical care environment, they are considered as one of our most precious patients, if not the most. I got trained for this, and I must admit that it took me a while before I gained the confidence in calling myself an ECMO nurse.
I'm an ECMO nurse. It's winter, so it's the busiest time of the year for us. I'm exhausted, but I love my job, so I need to suck it up. Let me just tell you more about what I do. This is not a ***** rant!
I am an ECMO nurse. You tell me that I only sit on my bum and do ACT every 2 hours, but you really don't have any clue, do you? I don't value doing the ACT itself, but the numbers that I get from it. I adjust the heparin infusion because I always want to get the balance between my circuit not clotting and the patient not bleeding his brains out. It is always a fine line, but we thread it carefully because we know the consequence of a very deranged ACT.
I am an ECMO nurse. I come with my flash light and I look for fibrins all the time. I search for newly formed strands and make sure that all existing ones are not getting any bigger. If the clot is in post oxygenator line, my anxiety level is high, for I know that if it dislodges, it goes directly to the patient, and the result won't be very good especially if it's a VA circuit.
I am an ECMO nurse. I send blood tests every 6 hours, and I correct whatever I can. If the hematocrit is low, I give my patient a unit or two of RBC. If the platelet is low, I make sure that I adjust the heparin infusion before giving a bag of platelets. All these things affect the smooth run of my circuit, and the worst thing that could happen is the machine just going to a full stop.
I am an ECMO nurse. I deal with plasma hemoglobin all the time. When it's high, I check for other signs of hemolysis like the urine turning pink. I don't want to be that random ECMO nurse who gets a high plasma hb after it has been normal for many days. It's either there's a big clot that suddenly appeared or I just forgot to remove the smart site before taking the sample. Either way, I still do my post oxygenator blood gas just to make sure that the oxygenator is still working well.
I am an ECMO nurse. Though I treat my circuit like a fragile baby, my priority will always be the patient. I work with you to keep this patient alive and to make him better. His hemodynamics, his sedation, and everything you do to the patient will affect my circuit in one way or another. So please tell me if you'll do something. I'm not trying to be difficult: the patient is alive because of this machine, so I just want our patient to stay alive.
I am an ECMO nurse. I don't mind working with junior staff. Everybody would have to start somewhere, isn't it? But if you give me 2 of them, with 2 circuits, and a filter, too, my stress augments together with the work; babysitting can be more challenging than keeping the circuits running. He doesn't need to be highly skilled and overly knowledgable; he just needs to have good planning skills, can act fast in an emergency situation, and most important of all, he needs to have the basic common sense. It's sad sometimes that common sense is not very common.
I am an ECMO nurse. I know you have done ECMO before, but there is a reason why you don't do it now. So if I'm not in the bedspace, please don't manipulate the bed and go up and down without me supervising it. It is my name beside that ECMO circuit, and it is my registration that is on the line if something nasty happens. You probably know what you are doing, but please let's respect each other's role.
I am an ECMO nurse. I know you haven't had an exposure with ECMOs before, and I'm glad that you sometimes admit it. If I call for a registrar and you don't know what to do, I'll explain to you what's happening and I'll give you some suggestions on what we can do. If I tell you that we have been having suckdown events because the patent is not properly sedated, please don't order to give 500ml Albumin to an already fluid overloaded patient. You are making the situation worst and you are not solving the problem. One note for you: Fluids don't always solve suckdown events. Trust me, I learnt it the hard way.
I am an ECMO nurse. I sometimes do a 12-your shift without any break just because there's no other ECMO nurse in the hospital. I try not to drink heaps of water, for I know that going to the toilet will be a mission especially if there is an unstable circuit. I get offered a urine bottle sometimes by my lovely colleagues, but I don't think I'd go as low as that. I would rather run as fast as I can, and do the deed in less than a minute, than to wee in the same room where I work. There are just principles that you can't give up even in the tightest of situations.
I could rant more and sound like a overtly cocky nurse, but I am tired, so I'll end it here. It could be ugly and extremely stressful sometimes doing what we do, but looking at all the post ECMO patients make it all worth it. The little child could start playing with his classmates who sent him well wishes when he was very ill, and the teenager could continue university and marry his beautiful girlfriend who was at his bedside when he was literally on the edge of dying. And so on with the greatest success stories in my career. It's a very challenging role, I must say, and it all started when I finally was able to call myself an ECMO nurse.
I am an ECMO specialist but my day job is being an ICU nurse, and I can tell you it is not even close. Let's be honest, when we have a balloon pump or VAD, mostly we just write down numbers, we had to learn a few assessments/checks to do and a few precautions to follow, and it is extremely rare for anything to go wrong, and if it does we just do what minimal, simple interventions we know how to do, panic, and call perfusion. Not necessarily in that order But you're still doing typical ICU nursing, it's another machine in your patient's room and it is critical, but it doesn't significantly change the general job duties. Being an ECMO specialist is an entirely different ball of wax. ECMO specialists require a few weeks of full-time additional training to become certified, it is not like getting VAD or ballon pump certified. When the ECMO managing physician isn't present, the specialist is the leader of the team caring for that patient, and you are responsible for anything that happens. You have to make complex decisions regarding management of anticoagulation, clotting, bleeding, and hemodynamics/oxygenation (the physiology and management is very different than any other ICU patient). You have three circuit pressures you are monitoring, three separate blood gasses to interpret to determine how to adjust your sweep gas and pump flow, but must also take into account pt. BP, native CO, gtts, patient lung function, vent settings, volume status, cardiopulmonary anatomy (e.g. in our congenital heart babies or neonates with shunts), type of support (VA, VV, VAV), where they are cannulated, patient assessment, circuit assessment, etc. etc. And even just the routine necessary things you do often require accessing the circuit, which is extremely high risk, as in if you turn one stop cock the wrong way you could cause a massive catastrophe. And if there is some kind of circuit catastrophe, until the ECMO doc, perfusionist, and other ECMO specialists get there to help, you alone are responsible for fixing it, while the rest of the ICU team that is coding the patient is screaming at you "how much longer?" Don't get me wrong, there are times on very stable patients where it's mainly just watching blood pump in a circle and jotting down numbers. That's why they say being an ECMO specialist is 90% boredom and 10% sheer terror.
To answer the OP's question, ECMO is scary and hard and it is not for everyone. It requires a certain level of passion, you have to be a little obsessive to soak in all the knowledge needed, and you have to be the type of person who is willing to be the only person in the room who knows anything about this crazy machine that is usually the only thing keeping the patient alive. I disagree with your statement that only perfusionists should staff ECMO pumps. With proper classroom, lab and clinical training experienced ICU nurses/RTs are qualified and capable to do the job, and do at most ECMO centers. It is not like you'll (usually) be doing full CBP with circ arrest. But that doesn't mean it's simple enough for a "ten minute crash course." That is completely insane. Our initial training is 80 hours, plus 4 hour comps every 3 months. Also, if they aren't offering you a nice pay differential, they are robbing you. When we sit a pump we get paid the same rate perfusionists get paid to run bypass in the OR. ECMO requires you dedicate much of your personal life to learning this, being on-call, and shouldering huge responsibility and high stress levels, and being exposed to some of the most emotionally demanding situations possible, above and beyond the demands of being an ICU nurse. The job absolutely deserves additional compensation.
Sorry for the long post and I know this is two years old. But when I saw one person say that only perfusionists should run ECMO and then another say it's just like a VAD, I couldn't help myself.
I work at a Children's Hospital that does ECMO in the NICU/PICU. But the principles here are the same. My concern is not an RN running the pump. We have RNs trained to run the pumps. These are experienced PICU or NICU nurses who work some of their shifts in patient care and some running the pump. One nurse for the patient, one for the pump. For cannulation, decannulation, pump changes, etc, a perfusionist comes in to assist. In our hospital, you need to go to a class (8 hours I think) and have precepted shifts with an ECMO patient before caring for them. Then there is a whole separate training and preceptorship for the pump AFTER you have lots of bedside ECMO experience. So my concern is that your hospital thinks it's ok to throw you at a patient with a "ten minute crash course" and two shifts later, ask you to learn to run the pump. It just makes me nervous for you and your license that the hospital would not put a higher value on training, education, and some bedside experience. I would definitely recommend getting pump trained if it interests you and you get some more bedside experience with ECMO, but I would ask lots of questions about the training (classroom and patient care) you would receive, available resources, and expectations. Seems a little fishy to me.
I didn't even start nursing school till I was 45. Went to ICU age 55.
35 is only a number. Only you can answer that question. Are you open minded? Are you willing to study hard? Are you willing to accept new failures and learning experiences?
You can be 20 years old and have none of the above and you will fail in the ICU. However the ICU gives you the opportunity to improve upon yourself.
The kids are going to have questions but chances are they won't ask out loud in front of people. Maybe pass out notecards for each one to write a question and then go through them afterward. It's also good to ask them questions and gauge their understanding of answers so you can get an idea of any misconceptions and correct them.
I'm not a school nurse but I have some experience doing STD prevention education for groups teenagers.
I was under anesthesia the only time one went in for me but I remember it pinching a little on the way out. 6 years ago when I had to undergo a water deprivation test, an Intern tried to tell me I'd be having a Foley. I politely told her where she could go. This was our conversation:
MD: "Are you familiar with the water deprivation test?"
Me: "I've done one on a three year old."
MD: "That must have been challenging with the Foley and everything."
Me: "We didn't use a Foley, we just weighed the diapers."
MD: "Well we're going to use a Foley on you."
Me: "Oh hell no..."
MD: "Well we need really accurate outputs."
Me: "Bring me a hat."
Oh hell no lol I would literally laugh out loud if my hospital told me I wasn't allowed to leave hell nope!
Can you pm me the name of your hospital? I am about to retire from the service and I need to work at a place that takes care of it people. Thanks sounds like your hospital is the place.
I've been in cath lab for almost two years now. I work in a high volume lab that runs a three person team in several rooms. Our hospital does most of the standard style cath cases such as EP study/Ablation/PVI/Left atrial appendage isolation/LHC with PCI/RHC/PPM/Loop Recorder/AICD/BiV/ASD Closures/PFO/Carotid Stents/IVC filters/Peripheral PTA/Atherectomy and Thrombectomy. All the cool toys Impella/IABP/CSI/Crosser/Laser/Turbohawk/Rotobladder/Angiojet/IVUS/FFR/OCT. As of now we do not do TAVR or any coiling procedures. With that being said, I have 5+ years ICU and Step down experience.
You better have your big boy pants on when you step into the cath lab. Many of our patients are stable, but many of them are deathly ill. Patients go bad quickly, much more so than on a nursing unit. Just learning the types of procedures and what the hell is going on can take a year. Mix in a whole host of new pharmaceuticals to play with and you can lose your mind. There is no pharmacy tech mixing drugs and putting them in a pyxis for you. You mix your own pressors and gtts. Its mind blowing just trying to learn the supplies associated with doing interventional cardiology. Like CCL RN stated, it really gets bad when its 3 am and you are doing the job of 5 people, mixing drugs, titrating drips, setting up equipment, monitoring vitals, assessing your patients vitals and rhythm, running a code, shocking/pacing your patient, pushing meds, getting thrown up on, dropping sterile supplies, and trying to document all this chaos unfolding.
I am sure there are cases of new grads thriving in a pre-op/recovery area for CVI, but it is not healthy for the RN to try to make this leap into the lab without some SOLID background in emergency/critical care/even paramedic training. You need to be 100% independent. I learned so many things in the ICU and even on step down. LVN's with 20 yrs experience have even taught me things I use in my practice today. Bottom line... Its not safe for your career or your patient. You need to know things like what you need to do if you perf a right ventricle during a PPM insertion without the MD asking, he's busy putting in the pericardial drain you dropped to him. What you do with a CHF patient that's BP/HR has tanked with an LVEDP of 35. Its almost like being the MD's ultimate resource. Some of the older nurses I work with know more than some of the Cardiologist doing the cases. My cath lab nurses out there know what Im talking about here.
I hope this reaches new nurses or nurses who want to get into the lab. Its the most rewarding job I've ever had, and I wouldn't trade any of the blood, sweat, or tears I have shed while working there. It has made me a stronger nurse with a huge skillset. Please know that every goal is attainable if you put in the work.
I have to agree with CCL RN. Especially if you are a new grad, you need to build up your skill set for a few years (yes, I said years). Having that base knowledge will make that transition to the cath lab much easier! For that matter it will make a transition to any unit much easier. That being said there are diagnostic cath labs and interventional cath labs. You MUST have a strong critical care backgound (second nature) before going into the interventional labs. When things go bad in an interventional lab it goes bad very quickly! Some cath labs only let nurses circulate cases where you are responsible for the entire patient plus, medicines, vents, Balloon pumps, Impella and on top of that you are also running to get equipment. I work in a large urban interventional cath lab where I am often the only nurse at night. I had 15 years of experience before I applied and I still learn new things all of the time. <BR><BR>P.S. I had to laugh at the "stand in one spot for hours at a time comment." That's a pipe dream.
You don't do "caths by yourself" and you don't "stand in one place for hours"
I actually work in the lab, do you?
I don't stand-at all. I work. Nonstop. Sometimes through the night. 12 hours would be a dream but its more like 14-16hr shifts...if I'm lucky!
I'm constantly moving. Fast. And wearing a ton of lead.
Most LHCs take an hour or so. I think you're mistaken on your time estimates...
Many labs differ ...but a true lab is NO place for a new grad, let alone a nurse without several years of critical care exp. if this is the case, then the are endangering pts lives.
Sounds like your lab is substandard.
I'm sorry, but it's true.
A new grad wouldn't last one minute in my lab. Not.one.single.minute.
We just turned down a nurse with 11yrs CVICU exp, 20 yrs total exp.
Please tell me how you will know how to run the pacer in a TAVR case, or run the IABP/Impella case.?How will a new nurse handle a crashing STEMI at 2am, IABP, anticoagulation, circulating the case, running the vent, anticipating te supplies, which pressors to mix and hang...all alone at 2am?
Tell me, queenjulie, what your cath lab experiences have been? Because I've been there. And it's NO place for the new or weak nurse...
oh, and I'm sure as heck not 'standing around for hours!'
Can someone please break it down really simple, elementary my dear: what is cardiac preload, afterload? Feel free to give specific examples with drugs that affect each to make it crystal clear, thanks.
Per Professor Carl Rothe of IU, the definitions are as follows:
Preload is the end-diastolic volume (EDV) at the beginning of systole. The EDV is directly related to the degree of stretch of the myocardial sarcomeres. This is the basis of the Frank-Starling Law of the Heart.
Afterload is the ventricular pressure at the end of systole (ESP). Ejection stops because the ventricular pressure developed by the myocardial contraction is less than the arterial pressure. This determines the end-systolic volume (ESV). Because the EDV equals the presystolic volume for a given beat of a ventricle, then the pre- and postsystolic volumes define the stroke volume (if the valves are fully functioning and there are no ventricular-septal leaks). The product of stroke volume and heart rate determines the cardiac output—the primary function of the heart.
Headache (for whatever reason) plus possibly very slight dehydration. As soon as she calmed down and relaxed, her blood pressure came back. Plus a bit of free water let her kidneys start working better and promptly pee out some volume, although you'll need numbers to know if the latter thing really took place.
Hypernatremia causes elevation of BP and it is treated by low-sodium fluids or free water.
Another thing that might happen is slight hypoglycemia (very common reason for headache), then juice should increase blood glucose, headache will be gone, patient calmed down and blood pressure decrease.
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