How I Stopped Worrying and Learned to Love the Monitor

A brief look at my first code as a new nurse and why you should always expect the unexpected (or at least be ready for it).

How I Stopped Worrying and Learned to Love the Monitor

I've been working on the cardiac ICU step-down for 8 weeks. It's my second day off of orientation and I'm beginning to realize just how much of the job my preceptor shielded me from. Its 8-something PM and I've just finished my first round of vitals on my patients. I walk into the medication room when I hear the gentle bing-bong bing-bong of the unit-wide cardiac alarm sounding. I'm ashamed to admit that I've already began to interpret this potentially lethal melody as more of a rhythmic nuisance. It seems to go off with even the most harmlessly subtle motion by the patient or the occasional electrode that decides to play hide-and-go seek. As I walk out of the medication room into the dimly-lit hallway, I notice the words "Cardiac X33" slowly creeping across the marquis. A subtle panic overcomes me as realize this false-alarm going off is one of my patients.

As I begin my swift walk over to the monitor, my phone rings with the words "war room" flashing across the screen. I answer just as the monitor comes into view but her words seem to meld in with the message above my patient's rhythm or lack thereof, "you patient in room X33 is showing asystole."

I sprint to the patient's room, she's laying in bed on her side, her eyes closed. I call her name once, she is motionless. I move in meekly for a sternal rub. I've already played the next few moments in my head but I'm still not ready for what happens. Just as my knuckle reaches her chest, she groggily responds.

"What do you want?"

I hesitate. It's one of those situations where you hadn't expect words to be necessary so you had none prepared when they finally came due.

"I just... needed to check on your heart monitor leads real quick" I quietly managed to mutter.

The patient rolls over onto her back and I quickly assess the problem. She has 2 leads that have escaped into regions unknown. A quick tug brings them back to the surface and I replace the electrodes. Slightly embarrassed, I make my way back over to the monitor to reassess her rhythm. It's noisy, likely the patient trying to rediscover her former position after it had been so abruptly disturbed, but unmistakably normal and present.

The next hour rolls by. I'm embarrassed that I made such a scene in my head over what turned out to be nothing. The cardiac alarm is still sounding. It's not my patient, but another one across the unit that keeps reminding me of my reaction.

Finally, I'm ready to sit down and chart. The cardiac alarm sounds again, I've already decided it's not mine but, as I was taught in orientation, I turn my head towards the marquis to be safe. "Cardiac X33". I turn again to the monitor and surely enough, she is back in the empty rhythm again, the bold red word "asystole" eerily hanging above it.

I briskly, but casually, walk to the room. Now knowing the leads are the culprit, I press the button on the wall to dismiss the alarm. The patient has returned to her side-lying state. I begin to check the leads, trying to be careful not to have to wake her again, when I hear the alarm return to sounding. Slightly irritated, I walk over and dismiss it again and return to checking the leads. The third time the alarm sounds, another nurse walks in.

"Is everything alright in here?" he asks, a subtle but clear alertness making itself present in his tone and demeanor.

"Yeah, I'm just fixing her leads real quick" I respond.

"Is she responsive?" he asks.

As these words escape his mouth, every CPR instructor and class I've ever taken roll their collective eyes at me. I move to arouse the patient with the same "sternal rub" I had used earlier. She doesn't stir. Her chest is abnormally still. He moves me aside and calls her name and more forcefully attempts a sternal rub. She remains motionless. It's 9 or 10-something. He pushes the blue button on the wall and I realize just how much of the job my preceptor shielded me from.

When the dust settles, the patient is down in the ICU. I'm relieved, she could have gone somewhere much less intense. I'm scared, I haven't been on my own for a week, I feel like I barely know what I'm doing, and I realize for the first time since starting this job that I could have killed a patient but letting my guard down. I'm still shaking, eternally grateful to the nurse who came in and saved what could have been a horrible introduction to nursing.

I have 3 takeaways from that night that I like to share with new nurses.

Stay Vigilant.

Alarm fatigue is going to happen. Always respect the fact that the time you least expect it could very likely be the time it ends up mattering to most. Even if it isn't your patient, be the nurse who saved another nurse who had already convinced themselves it was nothing.

Don't be afraid of needing help.

No one in the history of nursing has become an experienced nurse without first having been a new nurse. This was one of the hardest lessons I had to learn as I've always been irrationally afraid of people thinking I needed help because I was afraid of coming off as inadequate or unable to thrive in any given situation. That doesn't work in nursing. I've only ever known of one nurse who hit the ground running and, while I have a lot of respect for him as my senior, the nurses who trained him were more afraid of his confidence than any level of caution or uncertainty in a new nurse.

Be a team player.

The nurse who helped me saved both my patient's life and my drive to continue nursing. I try to live up to his example every day in my practice and be available and ready to help anytime someone might need me.

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jbeaves

About jbeaves, BSN, RN

I'm a relatively new nurse of less than two years doing my best and taking it day by day.

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In due time, it'll also become second nature to look over at the noisy alarm. I worked with a nurse who called everything artifact.... um no that would be vfib.

I do agree that alarm fatigue exists but I also think the more we are "aware" of it the less likely it'll be to tune it out. I know that sounds contradictory but I don't know how else to explain what I mean.

You're already a great nurse. Thank you for sharing.

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Specializes in Critical Care.

I have one question:

How did your preceptor shield you?

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My first use of the word "shield" is referring to more subtle tasks he would perform throughout the day either out of boredom or to ensure I did not become overwhelmed. Keeping track of medications pharmacy might need to send before they are due, monitoring I&O's throughout the day, reading up on patient's notes to make sure there was nothing I did not have to watch out for or expect. I guess more of a set of training wheels in this case.

The second instance is more referring to how my preceptor would be there to react in a code. He would know more of the patient's background to answer the barrage of questions, maybe have a better idea of what might have caused the sudden change whereas I was frozen and speechless. I knew why the patient was there, but I did not know how to state it as concisely and effectively as the situation called for, nor did I know how it could be tied to a change in cardiac function.

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jbeaves -

Nice article. It's a good lesson learned, and you won't forget it.

I have a question for you - did the "asystole" rhythm look any different than what was on the monitor when your patient was actually in asystole?

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JKL33 said:
jbeaves -

Nice article. It's a good lesson learned, and you won't forget it.

I have a question for you - did the "asystole" rhythm look any different than what was on the monitor when your patient was actually in asystole?

Both times it looked flat. Our monitor system has a habit of reading asystole occasionally while you can still clearly see a completely normal rhythm (this normally happens with errors in lead placement or sometimes just bigger patients) but I'm both instances all I could see was a flat line.

Of note, the cause was determined to be hypoxic cardiac arrest (she had been refusing to wear her CPAP) so I suspect it was real, albeit brief, the first time as well. After 7 minutes of resuscitation the patient became completely responsive.

While we prepared to go to the ICU she asked me if she was going home.

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jbeaves -

First off, I'm impressed by your title's reference to Dr. Strangelove. Ha Ha If it was unintentional, I'll only take off half a point.;)

Second, and most important, I second the sentiments of a previous commenter. This was a lesson well-learned.. and a blessing in disguise. You were able to set a standard for yourself early on without having to experience any lethal consequences! Honest mistakes can be made by anyone. It is a personal pet peeve of mine, however, to see another nurse assume that because patient X's alarm has been going off all night, "It's nothing. She's fine." Yes, it's tremendously annoying to have alarms going off repeatedly, especially if it's the same lead wires popping off or the O2 sensor that the patient won't keep on. Aside from the fact that I don't know if I could live with myself if I lost a patient because I willfully ignored an alarm, I'd rather run my butt off for that nuisance alarm than have to try to cover my butt later. I'm not at all claiming to be a goody-two-shoes or a perfect nurse. If for no other reason, a nurse should want to protect his/her license. That license is a privilege we worked to get. We should be willing to work to keep it.

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I like the topic. I try to get my coworkers to love the monitor as much as I do. Alarm fatigue is a huge issue. So make the monitor work for you. Adjust alarms so they are appropriate. This might include limits or the alarm value. For example narrowing rate alarms,ie if I have a pt on cardiazem or amiodarone, raise the lower to 60 or 70 as the med might be *too effective * and lower upper to 110-120 after gaining some control so you know if med is ineffective.

Also know lead placement. Frequently I receive a pt who rings for asystole all day due to one load reading that has such a low amplitude that it does look like that. Placement may have to go way off standard to get all leads to read. Remember the monitor reads all, not just the display lead. Also, pacemakers are sometimes challenging as leads may have to be moved to accommodate. You can go to your manual for the monitor to see the changes needed.

Review the limits, know the reasons for false alarms and how to fix them . Even frequent artifact can be and needs to be corrected. The wires themselves may be microfractured and need to be replaced.

Sounds like you learned to always check the pt first in the case of alarm. I just want to say help the monitor work for you.

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Good catch. You'll never ignore a false (or real) alarm based on this experience. Welcome to nursing!

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Great advice. I have one week left of my orientation on a med surg telemetry floor. Definitely nervous. Thanks for sharing.

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