TLCinCICU

It's policy where I work that you must aspirate from a sheath before pulling it. The theory is that any clot at the tip could be stripped loose as the sheath is pulled. It (in theory) could then embolize to the lower leg. If we cannot aspirate, we are to have 2 nurses dc the sheath. One is to connect the syringe and maintain negative pressure as the sheath is pulled. This all came directly from one of our senior interventional cardiologists. I'm not sure where he found the evidence to back it up.

Our facility runs Levophed at mcg/min, where many run at mcg/kg/min. The highest I have ever titrated Levophed was beyond our formulary max of 300 mcg/min. (My Kathi White reference notebook says 30 mcg/min.) This particular patient was a "heroic efforts" scenario - a younger man (with 2 young children) who had arrested while swimming laps. He was on dopamine, dobutamine, neosynephrine, levophed, and epi. He was vented and on an IABP. From the point I got report, I knew the day would be a hectic one. I simply asked the intensivist "Do I stop at the formulary maxes, or go on to ridiculous levels?" His answer - "Do what you have to do to get his pressures up." I was beyond the max on every single drip at the end of my day. I think I was at 20 mcg/kg/min on both the dop & dob, 1500 mcg/min on the neo, 500 mcg/min on the levo, and 150 mcg/min on the epi. Night shift added vasopressin after his first PEA code. His family let him go with the second code.

I attended a small gathering hosted by a physician that had the sole purpose of contrasting the healthcare plans of each of the two candidates. A healthcare economist spoke. His materials came from http://www.health08.com . The speaker did a fine job of presenting the material impartially, but he did say that in the end, the McCain plan would result in far more uninsured Americans.

1. how long (years) have you been a nurse? 8 years 2. what is your annual gross income? less than 30k, 30-40k, 40-50k, 50-60k, 60-70k, greater than 70k 60-60k 3. do you have an associate or bachelors degree? associate 4. how long have you worked for your present employer (seniority)? 7 years 5. on average how many hours do you work weekly? 36 hours/week 6. do you work during the week, over the weekend, both? both - work every 3rd weekend 7. what is your gender? male

The reason is simply anatomic. Arteries flow outward from the heart. Vein flow toward it. You get systemic distribution of the drug using a vein. Using an a-line will send the medication away from the heart. There would be quite a significant delay in therapeutic effect, taking into account that the return route from medication entry point to the heart and then out to the body is longer.

Between my prior position as a lab tech and my first few years as a nurse, I worked night shift for 12 years. I thought I had always handled the night hours well both physically and emotionally. I did, however, spend much of the first day off asleep - or just stay awake for over 24 hours and go to bed at night. I really, REALLY dreaded the loss of shift differential upon going to days. It was a significant amount, when you thought of it as a yearly sum. So I timed my change just as we got a raise. It didn't "hurt" as bad that way. Having a more "normal" life and circadian rhythm has made a tremendous difference. It's affected everything about me - social, physical, and emotional aspects, positively. And unless you have already "capped out" and are at your top wage for your position, you will eventually regain that loss of shift differential.

It's wrong to accept any kind of monetary gift/tip for our care from patients or families. Just think of how it could be if tips were allowed. Those who could afford to tip generously would receive the most devoted attention and "service" while the poor would get the minimal attention required by law. An economic bias (worse than what already exists in places) would then become built-in to healthcare. I had one patient send a card to me, care of my unit. Enclosed with the card was a personal check for $500. I just couldn't even think of accepting it. She then figured a way around my own personal ethics and donated to a nursing fund through the hospital. It will reimburse me for attending a future conference. The fact that she WANTED to make such a gift actually meant more to me than the amount of the gift...

Codes do give me a bit of an adrenaline rush, but I am much more pleased with myself after a day where I've felt like I've spent the shift about 15 minutes away from a code at any given point. I prefer being proactive - somewhat aggressive - and taking initiatives (getting them intubated, getting lines placed and drips started, etc.) and being part of the team effort to AVOID a code. After all, less than 15% of those who reach a code blue situation (in hospitals) survive to discharge - which includes those in vegetative states.

Nursemike - you and I think a lot alike. I would enjoy working by your side. I've had those same warm-fuzzies when a patient & his/her family asks "Are you back tomorrow?". You're also right about teamwork being such huge part of it - including the doctors, your peer nurses, and the aides/techs. I never even imagined the nurse having such a large collaborative role in a patient's medical care while I was in my little community college nursing program back in West KY. I work with some amazing doctors who have tremendous respect for bedside nurses. What does frustrate me is that it often seems we do more to satisfy TJC and third-party payers than we do the poor soul that lies in the bed we're assigned... Yet at the end of 99% of my days, I come home feeling that I've made a difference - even while my feet, lower legs and perhaps my back, ache. My education, my skills, and my instincts have helped someone on the return road to health. I'm glad I made the choice back in 97 to return to school and get an RN license. In comparison to dentistry, I don't have to run my own practice and I don't have to be available (usually) "in case of emergency". A dentist also rarely has someone in his chair that is truly happy to see him.

Running IV lines across a patient isn't a safe thing to do. I've seen patients get disoriented and pull on the lines, resulting in the IV pole falling into the bed with them - and sometimes hitting them. The "vent side" just happens to be wherever the RT sets it up, although we try to have it on the opposite side from central lines if there are multiple drips. The kicker is that we are VISICU monitored. So we are to orient the pumps so that the person in eICU can camera in and read the pumps. On a tangent, we also had a chronic vent patient manage to grasp his tube feed line and pull the pole into the bed with him. We heard the crash and walked in to find him with the tubing in his hands and stretched tightly across his own throat - deliberately. He went on "suicide precautions" at that point. It kinda points out that we need to arrange equipment around the bed with patient safety in mind, and then factor in our own preferences.

I half-expect that anyone who provides direct patient contact will be cultured for MRSA at least yearly. They could even choose to treat us "for prophylaxis" periodically in the pursuit of keeping the costs of nosocomial infections down. Our ICUs have just begun the practice of placing every admission/transfer into contact isolation and collecting a swab for MRSA. The lab does a rapid test for MRSA and the patient is released from isolation if it is negative. It came about as part of Medicare's "never event" list. If it can be proven that someone already was a MRSA carrier, they can't deny to pay for any MRSA infection by saying it was nosocomial.

Whenever pronation is ordered in either of our ICUs, we rent a specialty bed from KCI called the "Rotoprone". Before that, we used a brace called the "Vollman Pronator". It required multiple staff in order to use the straps and "flip" the patient from supine to prone. The head was stabilized in-line with the torso. The intensivist who was fond of ordering the treatment would stand at the bedside and maintain the airway. I think the Vollman Pronator actually padded the face and kept it elevated off the bed, keeping the endotrachial tube from being compressed beneath the head. The advantage of the bed from KCI is that continuous lateral rotation is used. Also, doors under the patient's backside can be opened to aerate the surfaces, relieve pressure, do dressing changes, etc. http://www.kci1.com/317.asp http://www.vollman.com/prone_positioner.cfm

I would chafe just as much with that preceptor. And as a preceptor, part of our duty is to allow/encourage you to chart and point out areas where you might not address required charting (like "comfort goal", which Joint Commission seems to want to make the equivalent of a Biblical commandment).

Thanks for sharing the story. Out of curiosity, what was the brand/maker of pump?

I'm with you. I've found the NIBP cuff set for Q60mins on vasoactive patients, and VS documented on CRRT patients Q60mins - when those patients are "hemodynamically unstable" by definition. I document at least Q15mins with a NIBP and more frequently if I have an A-line or the patient is deteriorating. I also try to precept orientees to do the same. Even if it's not written in a policy anywhere, it's CYA charting - and good practice.