Mimsy909

We are currently experiencing a most trying series of events in our unit and I would love to know if anyone else has experienced something similar and how your management supported you, your co-workers and/or the family. Briefly, and complying with HIPPA, we have a child who has been diagnosed with a potentially fatal, progressive disease. The parents have thrown up roadblocks to care starting in June that include refusing to speak with residents, calling attendings and hospital presidents at home in the middle of the night when a dose of Tylenol is ordered, shutting off infusions of dobutamine (for one), calling nurses criminals, stupid, threatening to find a nurse's wedding and 'trashing' it. They have left the PICU, with the child, no monitors or suction/O2/etc. and have disappeared in the building, PICC lines have been pulled out. They agree with a plan at rounds in the a.m. but when nobody is around in the p.m. they begin a campaign to discredit all that was decided upon. *Did I mention one of the parents is a physician who is employed by the corporation that includes our hospital?* The child is a sweet, sad little thing who does not need ICU level care. We have been forced to 1:1 the child for direct visualization of the parents 24 hrs. a day. The more confident, boundary setting nurses have never been assigned to this child. The younger or more malleable nurses have been bearing the brunt of this psychosocial nightmare. Child protection is involved and has noted there is ample evidence of obstruction of care and charges could be filed. Refer again, to *. Recently, our entire management team left the state for 2 days for a conference. We felt abandoned and wasn't sure we would be backed up if child protection was indeed called. Please share a story or two with me so I can help my coworkers know that we are not alone in this crazy situation.

Thanks Steve, that info looks great. We've had success treating the critters with NO and Sildenafil (our attendings do not want us to use the name Viagra). Fortunately, no ECMO. Since we've had a few admissions for PPHN and the parents were not prepared for what their preemie has now developed, this info will help all of us.

Our rapid assessment team is called the FAST team for First Assessment, Stabilization, Transport. The clinical educator and the transport nurse presented the development and concept of the team. They presented at a conference in Denver. Anyone see them? It's similar to what was previously mentioned, no physician's order is needed to initiate the FAST team referral. The PICU charge, transport nurse (if not out on a transport) and PICU 2nd yr. responds, we bring an airway bag and will stay to stabilize if things are going sour. We just need to continue to educate the floor nurses about calling sooner rather than later.

Recently we've seen an increase in NICU grads being admitted to our PICU after a short time at home. They are being diagnosed with pulmonary hypertension, something that's not mentioned to the parents as a potential complication of their prematurity despite courses that have included long-term ventilation with oscillators and d/c with meds and O2. We've had to trach and send home a couple with ventilators. Ethics aside, where might I find a couple of articles or information I might have available for parents to help explain this phenomenon? Is this something that any of you experience? The NICU is actually in another hospital across the street from the one I work in, two different 'corporations,' govern the hospitals, attendings don't collaborate across the divide to provide continuity of care for these little ones, but at least our residents work both sides of the street so when one of them bounces back somebody knows them. You can imagine the level of distrust that accompanies the parents. Any comments are appreciated.

Thanks for clarifying. We have a neat little bedside u/s machine and the tubes are placed by our CNS under direct visualization and are cleared right after placement to use. This is new within the last 6 mos. for us and since the tubes do occassionally migrate back into the stomach, maybe we should do this periodically? A lot of the kids get daily or qod CXRs and if they are small enough, the tube can be visualized but I'm wondering if we should be doing more.

What is a snap test for transpyloric tubes?

Within the last 5 years we went to standardized concentrations, eliminating the "rule of 6." Some of the reasons were cost conscious: all Dopamine comes in bags mixed off site (1600 mcg/cc and the lesser concentration which escapes my tired brain right now). Some of the reasoning reflected safety: all actual concentrations of drugs mixed in the unit were of different concentrations despite using a universal formula. A 60kg teen has a lot more epi in that syringe than the 4 kg baby in the next room on the same drug, running at the same dose. So, our pedi pharmacist, management folk and attendings created our standard infusion book. All drugs are mixed according to the 'recipe card' with a choice of concentrations (depending on fluid restrictions) and a graph is followed, one specific to infant, child or teen, matching the weight and the dose with the appropriate rate of the pump. This new policy also came with a pledge from the pharmacy that, other than the initial, emergent start of an infusion, they would supply all other bags or syringes of the meds. That part is still in the working-out phase. I have to say, it took a while for me to embrace this standard concentration thing. I felt like it was "too easy" to put a dopa, epi or terbutaline gtt together.....just follow the recipe, no math. No more easy increase or decrease on the dosing since 1cc no longer equals 1mcg/kg/min. you've got to follow the recipe card (We don't really call it that, can't think of another name right now) 2 RNs must sign all gtts on creating, even if just diluting Versed or Fentanyl, 2 RNs sign off at the beginning and end of shifts or whenever there is a change in the dose of a cont. infusion all part of a JCAHO safety audit. Mistakes certainly do happen but I like to think they're caught a lot sooner if we all pay attention to what we're supposed to do coming on and off shift and actually do it.

Hi all, happy to find this site. I've been an RN for 28 years, always pedi, and a PICU nurse for 24. I couln't imagine doing anything else, though I've tried! My unit is 16 beds, is multidisciplinary and affilitated with Brown Univ. medical school. We don't see cardiacs other than for stabilization and transport to Boston. We do have a very active transport team and care for some extremely ill children. Due to the general nursing shortage, our institution has initiated a critical care intern program where new grads can make the leap into the ICUs without prior experience. We offer them an extended orientation, an identified resource nurse when newly off orientation but.......then what? Several of my "older" colleagues and I want to offer some sort of support group to help them after they lose their first patient, encounter their first code, have the day from he** that we've all had (but know how to deal with). Is there anyone out there who has similar experience or wishes they had that or has a suggestion of how/what we could do for our new little chickens. Thanks. Keep up the good work. Mimsy