TraumaQueen

I currently work in a Level I Trauma/Surgical ICU. At our hospital, there is the ED and there are two large rooms inside of the ED where the traumas are brought. The trauma team responds to all of the traumas. For example, if it were a level I trauma... the team consists of: junior/senior surgical resident, junior/senior ortho resident, anesthesia, an ER nurse, a trauma/surgical ICU nurse, there are also trauma nurse specialists in house most hours of the day, the lab, xray, blood bank brings blood, pharmacy brings 7.5% hypertonic saline boluses, security, chaplain, house supervisor, an OR nurse... sometimes two... and of course the attending physician... and before you know it, there are 30 people in the room. We do intial and then secondary assessments in the trauma room.... if the patient is stable enough, we take them directly to CT scan.... if the fast sono was positive and the patient is unstable, they go to the or directly.....sometimes when they are stable, but we know they need to go to the OR, we take them to CT scan, then to the unit where we place lines and then head over to the OR..... but if they are coding when they come in, we have everything we need in the trauma bay to code, and certainly enough people! :)

Our balloon pumps are rarely if ever 1:1, our prisma is rarely if ever 1:1......heart transplants are always 1:1 to start with, VADs are 1:1 and the charge nurse helps, and if you're lucky other people have time to help too..... I have had instances where one of my patients were so sick that I gave up my other patient to a nurse who was less busy, even if it meant them being tripled. We are frequently tripled.... so much so that we keep a list of who was tripled last so it's spread out fairly. We do our best with what we have to work with.... but it sure is tough sometimes. :) I love my job, I love my job, I love my job. :)

We had a kid who shot himself because his girlfriend broke up with him.... she was pregnant..... The family of the kid who shot himself wanted some of his semen, so they could impregnate his step sister, so that baby could grow up and kill the baby the girlfriend was pregnant with.... They did more things than that..... but, that was by far the weirdest.

We have four - thirty minute visiting hours each day. Almost all of the families respect our schedule.... and there are times when we need to have the families in the rooms to help keep a patient calm. Some famlies don't understand our visiting schedule. Not many of our rooms are very large.... we have very very sick patients who often times have prisma, nitric, vent, keane bed, all the iv poles, random machines for cooling/warming, traction at the end of the bed.... so on and so forth.... sometimes there is hardly any room for more than a few people, and when these families don't respect TWO visitors at a time and try to crowd 10 people in the room for visiting hours, it makes it difficult to get to the patient.... I'm not sure if more or longer visiting would cure this problem..... Visitation time is always a difficult topic, because different ICUs take care of different patients with different needs...... We try to be a good judge of when to bend the rules.... but in general, all of our familes tend to agree that they want us focused on their family member, not them.

We have four - thirty minute visiting hours each day. Almost all of the families respect our schedule.... and there are times when we need to have the families in the rooms to help keep a patient calm. Some famlies don't understand our visiting schedule. Not many of our rooms are very large.... we have very very sick patients who often times have prisma, nitric, vent, keane bed, all the iv poles, random machines for cooling/warming, traction at the end of the bed.... so on and so forth.... sometimes there is hardly any room for more than a few people, and when these families don't respect TWO visitors at a time and try to crowd 10 people in the room for visiting hours, it makes it difficult to get to the patient.... I'm not sure if more or longer visiting would cure this problem..... Visitation time is always a difficult topic, because different ICUs take care of different patients with different needs...... We try to be a good judge of when to bend the rules.... but in general, all of our familes tend to agree that they want us focused on their family member, not them.

A pen light, calculator, I keep my drug books on my PDA and it's very handy for looking up drugs.....and, if you have a pda, it has a calculator on it. :) I also use my fast facts book quite often....and, it's always handy to have a few kelly clamps closeby. :)

we get 25% on the weekends and 15% on weekday nights

reintubation, blown ett cuff, reintubation again!, anxiety, xanax, ativan, dilaudid, a long overdue death, mini code x 2..... stressful sums it up!

If they aren't on pressors, etc.... most of our docs order a 5mg dose of kerlone post op and every day. Some prefer a 25-50mg dose of lopressor..... Personally, I haven't noticed much difference in giving it compared to not giving it as it relates to afib. More times than not, I've had kerlone come back and bite me in the rear, being the cause of having to go on pressors, heart blocks, etc......

If they aren't on pressors, etc.... most of our docs order a 5mg dose of kerlone post op and every day. Some prefer a 25-50mg dose of lopressor..... Personally, I haven't noticed much difference in giving it compared to not giving it as it relates to afib. More times than not, I've had kerlone come back and bite me in the rear, being the cause of having to go on pressors, heart blocks, etc......

Our unit also occasionally will send patients home. Now, this is a very rare happening, but sometimes we'll get a 'level I' trauma that had to be intubated for CT, but had no 'real' injuries, and we will discharge them to home when they're ready. RE: New Grads in the Unit I think it depends on the individual person, just like anything. Some new grads have no business in the unit, and some experienced med/surg nurses also have no business in the unit, no matter how much training you provide. As far as orienting new grads compared to experienced med/surg nurses.....aside from a little bit of organization edge, and more experience with assessments, it still seems to take them just as much time as a new grad (most of them), to pick up the new skills needed to work in an ICU.

Our unit also occasionally will send patients home. Now, this is a very rare happening, but sometimes we'll get a 'level I' trauma that had to be intubated for CT, but had no 'real' injuries, and we will discharge them to home when they're ready. RE: New Grads in the Unit I think it depends on the individual person, just like anything. Some new grads have no business in the unit, and some experienced med/surg nurses also have no business in the unit, no matter how much training you provide. As far as orienting new grads compared to experienced med/surg nurses.....aside from a little bit of organization edge, and more experience with assessments, it still seems to take them just as much time as a new grad (most of them), to pick up the new skills needed to work in an ICU.

And, TennRN, I know you read that article, just thought I'd post it for everyone else. :) And, as a final comment... you are totally right, it should be used early on. :)

We've just started using it in our facilty a few months ago. It's really great for all kinds of patients, they don't have to be next to death to be a candidate for APRV. The ventilator mode used is bi-level, and while bi-level is just a tad different than APRV, in that the low peep used in bi-level is generally not 0, and in APRV the ventilator uses the release time as an auto-peep generator. It's amazing to see the x-rays of these people before, and after bi-level. This mode of ventilation should be started early, at the first signs of trouble. One of the docs told me the other day that once they get so far into ARDS on say AC/PC, it's hard to switch them over to bi-level because they have no reserve for changes that big. Another consideration is fluid status. A patient who is very fluid dependant might need a few liters of fluid before bi-level is started.... This is also a weanable vent mode... you can wean them down to cpap settings and extubate from it. It's really quite interesting. here's an article that explains it quite well http://www.aacn.org/pdfLibra.NSF/Files/ci120205/$file/ci120205.pdf

One of our ding dong residents always spells pepcid as pepsid :) makes me think he's ordering some new brand of pepsi. :)

Our hospital has a protocol on running blood..... -however-.....I work in a trauma unit, and on patients that are bleeding out, sometimes a unit of blood goes in over less than 2 minutes..... Patients that are just getting a routine transfusion, usually get their blood over a few hours. It's purely situational. :)

Wesley, St. Francis and St. Joseph hire new grads -all- the time. (This is in Wichita)

I love love love trauma patients.

Generally takes 4 of us to turn, or pull up the bariatric patients, two on each side. We very rarely get the bariatric patients in our ICU. They go to the floor unless they have complications in surgery or respiratory distress afterward.

Regarding accuchecks/insulin/dextrose..... Blood sugars that are too low or too high can cause a patient discomfort, so perhaps your doctor feels this is a comfort care measure. Regarding the pacemaker.... It certainly offers the heart some benefit since it will continue to provide the heart with electricity, but as the heart continues to become deprived of oxygen, it will eventually infarct in an area of conduction and your patient will either go into a lethal arrythmia or asystole..... however, the pacemaker will continue to try and pace the heart even after death, so your death strip likely won't show asystole, but will have some electrical beats.

Since I'm spoiled and the pharmacy mixes our drugs for us.... the standard for the mixture is 1gram/250ml..... BUT if you have a patient that is recieving lots of fluids, and is at risk for fluid overload, they will mix it in 100ml. :)

I think it depends on the school you're interested in. We have a burn unit, neuro unit, cicu, but our trauma, surgery, transplant, open belly and general surgery catch-all unit is the unit of their choice for experience. Good luck! :)

I tend to keep my patients restrained until they fully wake up from their anesthesia and can get a feel for their mentality on the ETT. Some patients don't need to be restrained, and fully understand the consequences of self-extubation. We have a few CV surgeons that have orders for NO restraints because they feel it compromises the sternum. BUT... according to risk management, no matter what the physician has ordered, we can still restrain patients that are still under anesthesia. All of the nurses I work with are very good at judging which patients are candiates to leave unrestrained. I personally have never had a patient I left unrestrained, self-extubate. And, I've only have one self-extubation to my name, and that man was restrained.... just super bendable! :) At any rate.... it's a judgement call where I'm at....

That's really unfortunate. Don't let the bad attitude of a few people stand in the way of your goals and dreams. Our unit has a few nurses that are crappy to everyone, even eachother. You just have to either let them know they're being crappy or ignore them. Keep your chin up.... :)

We are always orienting new graduates, each graduating class.... except one, that I can remember. Hardly any 'experienced' nurses apply to our unit. We are an incredibly intense unit with lots going on.... and I think most of the nurses that have worked in nursing for a while are done looking for challenges (not all) and ready to find something more suitable for a relaxing lifestyle. (I know I will be when I'm older and nursing has taken its toll on my body) We do have several older nurses that have worked in our unit for many many years... but they are slowly dwindling away (retirement, switching to less work/stress areas)..... and, while they are a great resource for learning, so are the younger nurses. Not all of our orientees make it off orientation, but the ones who do usually do exceptionally well. We're incredibly organized and focused on the learning we expect them to do while on orientation. Is it scary that most of our nurses are new? I'd be lying if I said there weren't nights when I look around and think... dang, our most experienced nurse has been here for 3 years. But, when I look around at the nurses that are there, and have survived our orientation, and have been doing well in our unit for 2-3 years.... I know that I'd trust any one of them to care for me or my loved ones, because I think that's how good of a job we do with our orientees in the long run. And, barefootlady has brought up an interesting point as well. I've overheard managers of units say they prefer new grads, because you can mold them to be the way you want them to be..... no bad habits, no attitude.... fresh and excited and they're like damn sponges. :) Personally, I think it takes a mix of old and new to make it work. :)