23AtTheTeeth

Well, it was a little more in depth than that... I asked if we could start dobutamine to help with her saggy indices and CO, but she said to try and go up on the milrinone from .375 to .5 first and then re-assess instead of starting a second agent (per the Res and the Attending). I said okay, 10-4. My manager said that, in fact, wasn't okay, and I should have known better. FML, right? Because that's my responsibility, and also MY call to make. Apparently.

Hey, all. I am a Cardiothoracic ICU Nurse at a Level I Trauma Center that is also a major teaching hospital that serves 9 states in my Region. Needless to say, my unit is extremely busy, and we fly patients in to provide surgical specialty care and emergency resuscitation regarding anything Cardiac. As many if you know if you're a member of a teaching hospital team, the steady migration of Resident Physicians through your unit can be somewhat annoying, and for lack of a better word, horrifying. As a newer nurse on the Unit (not in general) I have been there for a year. The turnover is astronomical in regards to nursing, and it seems as though as soon as we have a full staff, the ones who are left quit just as the new ones are ready to fly on their own (somewhat) confidently. This bodes a problem for the new baby doctors that are "in charge" of us, because, as the sad jokes go, we often know better than they do what our patients need. I'm not implying that we are smarter, or better... just that when an anesthesiology resident is doing a rotation through CVICU that is not his/her field of study or expertise, but it IS mine, and I have been doing it 70+ hours a week for a year, once in a while I feel like my judgement is a little more sound at times in regards to certain things. The other day, I had an extremely complicated patient that was not doing well, despite every single intervention I could muster, every brain cell I had scraped together, I called in every single senior nurse on the floor to ask for advice, including my charge nurse. Together we came to our resident (who was actually quite competent) with a game plan and our rationales, and she said she liked the ideas, but due to the complexity of the patient, she felt she should run it by our Attending, which we all agreed would be best. Long story short, the patient still is not doing well, sometimes they just can't be fixed and they don't get better... but, I was reprimanded by management, being told verbatim "Residents look to us for guidance. Why would you let them do that?" Is it just me, or is that statement in and of itself just absolutely INSANE? Why would I let a DOCTOR do something? It's my job to not only self regulate every single micro-move I make in regards to my patient, but I also have to babysit a doctor for my entire shift as well? Like it's some, unspoken but well known rule?

I started in a Level I Trauma Center CVICU at the end of last year, and it has proven to be the most challenging/rewarding thing I have ever done. I, too, transferred from a leadership, Charge Nurse role at a smaller hospital to a staff nurse at this teaching hospital. I was astounded at the level of expertise, skill, and knowledge every single nurse on the unit had, many of whom were younger than me. Not only that, but I felt from day one that I was a brand new nurse all over again, because Cardiac ICU is like nothing you have ever seen or done before. It is the exact opposite of everything you are taught in school. We even have our own ACLS (CALS), we do CPR and resuscitation different. CVICU is the top of the totem pole. I don't mean that other nurses are not as smart, or as skilled... I just mean that CVICU patients, open hearts, experience all co-morbidities under the sun while under your care. Strokes, GI bleeds, sepsis, shock, aneurysms, respiratory failure, kidney failure, shock liver... you see and treat it all. You fix it all. I do my own dialysis, neuro checks on a Neuro ICU nurse level, CRRT, we administer chemo to our patients who have cardiomyopathy secondary to their cancer, we do lumbar drains and bolts and pins, we do full C Spine precautions for the patients who have blunt force trauma from car wrecks, we do postpartum care for the mothers who have postpartum cardiomyopathy. Literally every kind of nursing you can think of will come into play in CVICU. Just be prepared to be challenged, to fail, to get back up and be better the next day. Your comfort zone no longer exists.

I don't know, I am not on board with "just giving the guy his coffee." If you were to give him his coffee and make him go over his restriction, you would be directly breaking a physician's order. I think the only thing different I would have done was to talk to the doctor about either increasing the restriction or lifting it completely. I think they're BS anyways. Seriously? You think we are going to work our asses off tuning someone up who is so grossly non-compliant and they're NOT going to just go right home and drink their heart into oblivion? Yeah right. I wouldn't have given him coffee either. I would have said, "I just barely met you, I don't know anything about you or your case. You just got here. I am going to need about 10 minutes to look at your chart. I can even stay right here and look at it right here if you'd like?" What a tool. I'm sorry that happened to you!

I can see your rationale behind not using CVP alone, but all of your other hemodynamic parameters seem to indicate that he was definitely fluid up as he was hypertensive, extremely high PA pressures with a high CVP. If it was just one outlier, I can see not blindly treating CVP, but all three point in the direction of being fluid up. The amount of time the patient was on bypass will directly affect kidney function and almost always causes some sort of acute kidney injury that usually presents 2 or 3 days post op. I would have definitely suggested diuretics, if not some push-pull with diuretics and concentrated albumin to improve those hemodynamic parameters. His SVR is high enough that he is indicating he's clamped down, and could use some albumin but has a lot of fluid to give. A SPB of 140 is way too high for a CABG, so nicard was a good choice for sure. I think lasix, lasix, lasix (depending on kidney function) maybe some diamox and nicardipine, and restarting the milrinone wean once he is a little more fluid negative and can tolerate it.

Honey, I am proud to say that you officially had your first #**** day! Some days, even as a Cardiothoracic ICU nurse, all I do is bed baths and linen changes after code brown after code brown. The key to being an amazing RN is mastering being an amazing CNA first. Learning to quickly change beds, change briefs, multi-task, prioritize non-life threatening tasks and master simple skills that you will have to be doing 4 or 5 at a time as an RN is pivotal!! It will get better, you WILL have your time with a nurse, and she will probably brush you off, treat you like crap, make you think you're stupid (you're not) and act inconvenienced by you. That is just the way of the world and the nature of the beast. Once you're out in the world, you will be a new nurse, and it starts all over. I promise you you will look back on this and be thankful for your experiences, and you will have learned so much in the process. Keep your head up, I promise it gets better, you are making a difference, and you are learning the whole job. xxoo.