feeling so stupid

[charlie1234]

Hi there,

I have worked in icu off and on for the past 7 years and feel like I know less now than when I was a new nurse!! I used to feel smart and read all the time and I guess now, I've become complacent and burnt out. Yesterday I did something that shocked me--I did not think, and I have been beating myself up and torturing myself since. Have you ever done something, not questioning whether it sounded reasonable, to think after the fact "why did I just do that"...."I know better"? Well, we were about to intubate a 84 year old gentleman who was on dialysis (this fact I should have clued into), as he was very aggitated and obviously hypoxic. There was a 3rd year resident and pulmonary fellow, plus an rt in the room. I had the intubation meds and clearly heard. "alright-give 4 mg midazolam, 30mg etomidate (he was 6 ft 3 inches and 83 kgs) and 100 mcgs of fentanyl. I thought we were ready to go and as the man was so agitated-I gave the meds and bam-he was out. I announced the meds were in, looked up to find 2 panic stricken docs who replied" what, you already gave them??". We quickly bagged and had an uneventful intubation, but I felt like crap!!! THe normal me would have proceeded a little more cautiously and would have looked up and verified each drug, ensuring everyone was ready. I was so focused on his iv stuff and probably hypoglycemic that I just acted. Then, to make matters worse, the attending came in and said to the docs "jesus guys, 100 of fentanyl, that was a bit much huh"? The resident said "there was a little communication error". The attending chastsized me and explained the doses "we usually give" so I would know what to expect-starting with 2 mg versed, usually 20 mg of etomidate and starting with 25 mcgs of fentanyl. Well,,,needless to say....I felt stupid. THe mans pressure held throughout and after the intubation, but he was severly septic and possibly having a lower gib. THe effects of the meds wore off within 30 minutes and he was a rass of 2, appearing in pain and aggitated, overbreating the vent. I went to lunch and the charge rn assisted with the insertion of a arterial line. She administered 50 (maybe 100-unsure) and 2mg more of midaz. His pressure was in the 60'ss systolic at that point- an hour or more post the intubation. I think he was getting sicker as a result of the above mentioned factors. But my mind was set on the fact of "omg did all the meds I gave hang around because his creatine is 3.20 and now I caused this situation to be worse?". He ended up getting 7 litres of fluid his cvp started at 7 and I got it to 12 and it would fall to 10, and I started levoped maxed to 40 mcgs.min with little response. I felt so frustrated. The docs were nowhere to be found and seems unconcerned that his pressure was in the 60-70's systolic. Thought the a line wave was fine, zeroed, flushed, etc; I checked a cuff bp which was 10-20 mmhg higher in the 70's-80's. Still, I suggested vassopressin, due to the fact he as acidotic. I also requested a stat cbc as I noted his abdomen to be more firm with a slight bruising (suspecting bleeding). He did have melanotic stools prior to admission with a hct of 24 on admission with 1 unit prbc prior to arrival. The cbc showever 7.7/23.3. I asked if we should give blood. That was at the end of my 12 hr shift. His hr was 140's all day but after the fluid and pressors was down to one teens. How can I stop feeling so bad? maybe it's time to quit icu. Any words of wisdom would be greatly appreciated. Thanks

[detroitdano]

This is why I never give meds in a code/intubation situation unless I know 100% for sure the doc wants them right then (i.e. Amiodarone in V-fib and someone is screaming for it) the doc is right next to me to verbally repeat what I have in my hands and I can ask if they want it in right then.

[netglow, ASN, RN]

:kiss

I have adopted the "2 of versed going in" then pause holding syringe in air (announcement) with looks towards MDs with eyebrows raised. Then if OK'd, it goes in and then I say "Versed's in" I know, a little much but sometimes you get a "huh?" and I am new.

[meandragonbrett]

I always verbalize what I am pushing when I push it when doing something at the bedside. Just a habit I learned from the very start.

[kimmie518]

Don't beat yourself up over it. It was a communication error on both parts. I think the physican was wanting you to pull out that much, and not give....

Thankfully, the patient was still successfully intubated.

[tri-rn]

You said in your post that the gentleman was at RASS +2, agitated, and overbreathing the vent 30 mins later. Also, he needed additional versed and fentanyl for ART line placement. Those facts tell me that he recovered from what you gave him, no matter what his BUN and creat were....as far as his SBP goes, you said yourself he was "severely septic".....

You made a mistake that could have had serious consequences, but it doesn't sound in this case like it affected the overall outcome much. From what you said, this guy sounded pretty sick and everything that happened would very likely have happened anyway.

Please don't quit the ICU. We need nurses who care enough to learn from thier mistakes. There are too many that don't care enough - or think they are too smart/too experienced - to spend the time on a little introspection.

One thing I HAVE learned (even though I don't have your years of experience) is to always carry an energy bar or something. My brain shuts down if I don't eat.

[nursewendy376]

No need to feel stupid, just learn from your mistake. Don't let docs(or any one else rush you). I always repeat back to the physician, "You want me to give .... , correct?" If they get irritated because they feel you are moving too slow, that's on them, and they will get over it. We are human, after all.