Baptism by fire...vent session

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Specializes in CrItical Care, Street Medicine/PHM, School nurse.

Hi all,

I've been an RN going on 5 years. My first 2 years were at the bedside in IMC and the last 2 1/2 were outpatient. I recently returned to the bedside but to a 40 bed ICU unit. I had an 8 week orientation (most was COVID related) and this last week was the first week on my own. My first week was what I like to call baptism by fire. I don't really have anyone to vent to so I thought that you all might understand. Sorry for the long vent.

My first assignment was a trauma patient that had 2 crani's in the last 3 weeks. She was on precedex and fent to help keep her from fighting the vent, mostly due to the large amount of secretions that caused alot of coughing. She had a fresh trache as well. Her BP was soft with SBP in the 90's and HR in the 50's. No pressors. 

Yesterday she spiked a fever of 103 and had increased serous drainage from her crani site. A head CT was ordered. Given this patient's vitals and inability to lay flat, I was asked to try a combination of sedatives and add on Neo for BP support as additional sedatives will bottom out her BP (she was already soft to begin with). I added a low dose of propofol, increased fentanyl, and kept precedex the same. She was still unable to lay flat without coughing and her HR actually went down and maintained in the high 40's. I believe this is due to the reflex bradycardic effects from Neo and the precedex as well. I tried suctioning her before laying her flat. I felt that increasing or adding more sedatives would make her dangerously bradycardic. I consulted with the MD about what else he would like me to do as I did not feel I was able to adequately sedate this patient and maintain her in a somewhat safe range. 

The MD went to the room, messed with the sedatives (increased propofol, turned off precedex, increased the Neo, maxed out the Fent). The patients HR dropped to the 30's but she was able to lay flat without coughing. He then administered Ephedrine and increased her HR to the high 40's. He asked me to leave STAT to CT. The patient was packed in less than 5 minutes and a team arranged to help with transport (RT for vent, 2 techs, charge nurse, myself). The MD gave me a syringe labeled with the remaining ephedrine and asked me to give 1 CC every 5 minutes if she dropped under 45. The team flew to the elevator, down to CT, and back in less than 20 minutes without incident. I thankfully did not have to administer any ephedrine or increase her sedation.

I was so incredibly nervous during this entire time! This was my second time ever having to manage anything other than propofol or versed (my orientation was pretty limited). The critical care MD was very patient during this whole event and tried to teach me why he was doing what he was doing during every step of his actions. He even offered to go down with us to CT but we already had enough people going so he stayed and texted me while I was in CT to check in. Earlier that day I assisted this same MD with a bronchoscopy at the bedside (something I had never done either). My charge nurse, RT, and techs were also wonderful in helping me. In talking with the other unit nurses, they felt that this situation was risky but thankfully worked out. Despite the support, I can't help but feel that this was a baptism by fire and I have not even really experienced what it's like to have an unstable patient. 

Anyway, just needed an outlet to vent. Any recommendations for keeping a journal during your nursing career? Or do y'all just find a colleague/friend to talk to? My current friends would not understand. 

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Specializes in CrItical Care, Street Medicine/PHM, School nurse.

I did want to add that I had asked the MD about possibly changing to another pressor, such as Levo, that might help increase BP as well as HR but he decided that we should try what we had hanging already. 

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Specializes in ICU, travel.

You're doing a fine job.  

With a lot of years behind me, I'd probably look to ditch the Precedex and up the Fentanyl, and maybe ask for a push or two until the fever and secretions get sorted out.  Her brain could have herniated, or something else could have happened (though usually temps rapidly plummet when they brady down), but I don't really know because I wasn't there, and even if I was there, years later, sometimes I don't know everything.

Keeping a journal is great.  I've been encouraged to write over the years, but it's not for me.  I do standup.  If I can make an audience laugh over what happens to me, it's kind of cathartic, like if I can make something coherent out of my experience as a nurse, maybe I do have what it takes, both in comedy and nursing.  And in both fields, you see and experience things that are so alien, twenty years in, it feels new all over again.  

I'm not sure what the other unit nurses mean by "risky."  The patient was unstable.  Probably why she's in an ICU.  You know the situation is risky.  You're looking for information to decrease the risk and stabilize the patient.  On the plus side, having an RT, charge nurse, and two techs to help roll you down for a head CT is outstanding.  

Hobbies outside of medicine, healthcare, etc. go a long way toward staying sane.  

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Wow, what an incredible story!! You did absolutely amazing, and it sounds like you had such a wonderful team supporting you through such an intense experience! You should be very proud of yourself ? I agree with you recognizing the bradycardia from precedex, I may have shut it off or decreased it by half. It’s hard to know with multiple drips, sometimes it’s a trial and error but it sounds like you didn’t have time for that and the provider was wanting to keep precedex on board (that doctor sounds amazing by the way). In that situation it sounded like it was a race against the clock. Yes it was risky to go to CT but you had no other options and the patient was continuing to deteriorate, you needed more answers. So it would have possibly been a worse outcome by not going. You did such a wonderful job! 

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Specializes in CrItical Care, Street Medicine/PHM, School nurse.

Thank you all for your advice and support!!

I’m definitely going to look into more hobbies. I feel so exhausted but I know I need to keep my mind occupied on my days off. 
Sadly, this poor patient ended up herniating a few days later and the family decided to withdraw care.

I am reminded of our mortality and fragility every day at work. I try to cling to the very few miracle moments that present themselves. 

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Specializes in oncology.

I appreciate your discussion of what you encountered. It does seem like 'baptism by fire'. I wish I could ameliorate what you have and will continue to go through. 

While I never had experiences as you described, I did find hobbies that helped. I was always into fashion but couldn't wear to for work. Instead I looked at antique/vintage fashion. I find a thrill in mending a dress that has survived since the American Civil War. I like to polish boots from the 1850s to the 1890s. I do that while I watch TV!. I collected so much I found a place to re sell it and met people from a whole different walk of life. Going to auctions and estate sales took my mind out of nursing

 

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