CindyCCRN

We are all HUMAN... ...I guess I know inside that this or a similar incident could easily occur in the ICU I work in - as staffing, workloads, and work conditions are UNSAFE and DANGEROUS .... There are many major systems failures that HINDER SAFETY... (...and yes, that is why I am actively job hunting)... ...This is truly a very sad tragedy - both for the patient and his family AND the nurse and her family... I totally agree with jt that alot of other information and insight into exactly what was going on in that entire unit - entire hospital SYSTEM requires investigation... Obviously, if no one responded to her calls for help after the patient became distressed, all the staff were extremely busy... Was staffing ADEQUATE? What were the other WORKING CONDITIONS? ...Were both of these patients assigned to this same nurse - did she have others too??? ...Being a long term ICU nurse - I can clearly imagine how many tasks she had to perform in very little time... Proven Fact = "STAFFING" determines ICU Patient Safety... I have no doubt that she IS a very competent and skilled critical care nurse... Medication Errors are NEVER solely the fault of just 1 person - There is always a whole series of failures that lead up to the error = Root/Cause analysis... ...Were both of these meds dispensed in unit dose and clearly labeled specificially for each patient? ...Was the tracrium ordered as a bolus dose or a continuous infusion? AND was it marked in a bold and bright label with warnings - per manufacturer guidelines? ...Where was the vancomycin infusion stored - next to the tracrium?? ..Was it hospital policy that 2 nurses check ALL NMB administration for safety, etc...or would that have been too timely and costly??? ...WAS the error immediately recognized and treated - ETT + ventillatory assistance, CPR, etc... PLUS ADEQUATE DOSES OF ANTICHOLINESTERASE REVERSAL AGENTS AT THE RIGHT TIME (10 mins or so) - such as neostigmine? ...I would like to extend my deepest sympathy and many prayers to Mr. Magdziarz and his family and Ms. Metzger and her family... .....Have the Courage to embrace the truth and ALL it's consequences....

Hi, Cheryl! I have worked ICU/CCU for many years - lots of Hemodynamics (love them... teach them!). We have very specific standards for all policies and proceedures, according to recommended critical care safety guidelines. Routinely, PA lines are never wedged more frequently than q4hrs - often less, per individual Dr's order. Actual occlusion of pulmonary artery can cause rapid and severe distress in some patients. (have seen some patients develop immediate chest pain, ST elevation, dysrrhythmias, BP changes, respiratory problems, etc. with pulm artery occlusion - PCW). PADP should always be 0 to 4 less than PCW, if line properly positioned... can use initial PADP minus 0-4 per Dr ok, for PCWP/LVEDP/LAP estimation and calculations, most of time... If in proper position (optimal = lung zone 3), should wedge with between 1 to 1.5cc air - never more... If a catheter wedges with less than 1 cc - indicative of tip being too distal and line usually needs to be retracted. If no wedge obtained with full 1.5 cc air - usually tip too proximal and line needs to be advanced... After insertion and Xray confirmation, nursing should mount strip recording of PA and PCW waveform - helps future detection of trouble... and always note exact depth of insertion to tip of hub (and communicate to next shift). Most all catheters are 110 cm long with markings every 10 cm = thin black line and 50 cm markings = thick black line... Also, great to know normal insertion distances, depending on site ... from Int. Jug. - PA normally 40-55 cm, from SCV - PA 35-50, from Fem vein - PA insertion normally about at 60 cm, from right antecubital - PA shouild be at about 70 cm, and from left antecub - PA line should be inserted to about 80 cm. for proper pacement and accuracy.. When wedging, we always have respiratory pattern visible and never leave catheter wedged for more than 2 full respiratory cycles - often less, if acceptable PCW waveform visible. We then edit all PCW waveforms for ventillatory effects and artifacts from pleural pressures. To avoid artifact, always read the waves at end expiration (when pleural pressures and atmospheric pressures are about equal) - choose the last clear wave that is not affected by breathing - before next inspiratory dip (when wave starts to be pulled down). And as explained by PatriceM, depending on pt. - spontaneous breathing = "peak" vs. mechanically controlled ="valley"... Then, we determine accurate PCWP by interpreting hemodynamic waveform... Each PCWP may contain 3 waves - 1. "a" wave (pressure rise due to atrial contraction) - usually the largest wave; occurs near the end or after the QRS. 2. "c" wave (mitral valve closure... rarely visible with PCW - more visible with right sided CVP waveform and tricuspid closure) - 3. "v" wave (atrial filling - vent systole) - located after the T wave.( the T- P). The 2 Acceptable Methods to read PCWP are: 1. "Mean of The "a" wave - most accurate method of reading the PCWP is to average the top and bottom values of the of "a" wave; unreliable with mitral stenosis, AV Blocks (at fib, flutter, paced rhythms = absent "a" wave, or junct rhythm, "cannon a waves", etc... ...Then must use alternative for correlating with EKG strip... (Remember, electrical activity always occurs before mechanical)... 2. Z point Technique - useful when "c" wave is not visible and the "a" wave is abnormal. This method assumes that 0.08 seconds (or longer) after the end of the QRS complex correlates with LVEDP... So to read the PCWP via Z point- simply find .08 sec from the end of the QRS and draw a straight line down to the EKG - this the PCW value! ...Cheryl, Oops! ...I think I got carried away. But I do love hemodynamics and this is only a small piece of understanding them... I hope I helped with your question.... Cindy

...I think I submitted twice... Sorry!

Mario, Mario - quite an amusing "gut" interpretation of your heart's newly discovered squeak... ..I do believe you... it's probably your heart... ......I love heart sounds, EKG's, hemodynamics, etc... ...Heart sounds are made by the flow of blood - turbulence -through valves and chambers... pressure gradients... S1 = Lub = systole = closure of AV valves - mitral and tricuspid S2 = Dub = diastole = closure of semilunar valves - aortic + pulmonic ...learn where to listen for each valve - it's fun! Many people have slight abnormalities of their heart or great vessels which yield unusual sounds, but they're perfectly healthy. As with children, innocent or normal heart murmurs are quite common - most disappear by adulthood - some don't and are intermittently audible.. Great site = http://www.wilkes.med.ucla.edu/intro.html Have fun with this!

Hi, Tattooed-nurse to be... (I like your user name)... In ICU, where I'm staff, unfortunately there aren't any monitor techs. The hospital uses them on the Intermediate and Telemetry units. I've been floated to these units and am fairly impressed with the techs. They certainly seem to know their rhythms and that's a great help to the unit staff. In ICU, our central monitors are often unwatched and we depend much too heavily on bedside monitors and alarms. Of course, staffing is pretty pathetic... so, much of the time - all the nurses are at the more critical bedsides and more than half the patients are monitored by alarms only. ...I do alot of ICU precepting and recently precepted a new GN (6 month preceptorship) who had been a monitor tech on the telemetry unit during her last year of school. She did really well and her exposure to tele and cardiac monitoring certainly was a plus... Good Luck with your monitor tech position + nursing! .....Remember that none of us are responsible to care for the whole world. The best we can do is care for a world of individuals - one at a time... ...

Hi, everyone! Yup, I agree this is a rather touchy subject... But, after 25 years + of ICU Nursing, I choose to comment. Over 10 years ago, I worked with very few male nurses. I did feel that most of them functioned on a relatively low-level compared to the many top notch female critical-care nurses I witnessed. And yes, being a strong minority, they did seem to be offered advantages and promotions that were unavailable to much more competent and deserving female nurses. More recently, there has been a great influx of male staff RN's into our ICU. At this writting, 30+% of our full time RN staff is male and many more daily agency staff are also men. My perspective has changed greatly. They are all highly knowledgeable, very competent, motivated, compassionate, caring, and energetic team players. Our male nurses are a real asset to the unit and profession. For the last 2 years, my partner (2 nurses who work the exact same schedule) is one of the dearest people and best nurses I've ever worked with - yes - a male RN... ...I think our nursing profession might not be in such a sad state of affairs, if we had many more male RN's... ....It is easy to get opinions from people who tell us what we want to hear. But the only really helpful advice is hearing the truth, even when painful.....