CactusFlower

Sorry for your experience, but hang in there. You learned alot from this patient, and recieved some very good advice and thoughts from the posts here. Personally, I have worked on pt's that there was no limit to the levo. I've gone over 250 mcg/min--switched to delivering it as mcg/kg/min, added numerous pressers, inotropes, bicarb gtts, albumin, lasix gtts--even adding the lasix to the albumin gtt. Had afew pt's on two vents, CRRT with this mottley crew of vasoactive substances and afew made it, most did not. With these types of pt's couldn't and wouldn't have done it without adequate hemodynamic monitoring and a doc at the bedside. I agree with the previous posts--good advise--was this pt wet/dry/septic/CHF--you reported to the docs and got only so far. Regarding the mode of mechanical ventilation--with a pt post arrest, deteriorating, plus this restless and aggitated CPAP just wasn't appropriate. WOB has a major impact on oxygen consumption and you started out at a dead run. The only other thing to consider--maybe the docs knew something more and were not filling you in. Maybe they had a preconcieved point, were only going so far with this patient and were waiting for the family to come to terms. This sucks big time--leaving you at the bedside to fight the good fight, deal with the family and be left second guessing yourself. This does happen--some docs just don't feel they should be bothered when the end is iminent and the family in their opinion "just don't get it!" You get caught up in the gray zone of doing everything that you can or do you do everything that will work. They need to communicate to the nurse at the bedside giving their all, sometimes alone trying to deal with what is at hand and a family going thru the worst time of their life. What your docs should have done is to be there too. Anyway, good post, good ideas and advice. Go on and fight the good fight Nurse!

Really enjoy the input here--and sometimes miss the days of the Swan. Yes, yes, we can go on and on about not having them used. It all boils down to the patient responded and got better. Good job!

Thanks guys for all the input. This whole situation boiled down to the RT not suctioning, the nurse (me) suctioning. When the patient was suctioned for lots of secretions, it was an appropratiate intervention. To justify not suctioning (ever) by claiming that current research and evidence says to unequivally not to suction-- was a dumb move by that person. Again, I work in a small, rual ICU with a nursing population that does not suction, they call respiratory. Not critizing here, but I am teaching a new grad nurse to function in this ICU--how to assess, how to do certain things. Throwing out bold statements as "fact" and standard of "practice" is wrong. I do not want to offend anyone here, but I think nursing can assess their patients and take the appropriate action when necessary. It may just boil down to the fact that we must all play nice in the sandbox! But, again, I am alarmed by the fact that both nursing and respiratory (here) believe that it is detremental to the patient to suction under most, if not all circumtances.

This particular patient had a very big pneumonia and pulmonary edema. She was a postoperative abdomen and did not do well. I haven't seen any current literature that supports the stance of the Respiratory Dept here, so I will continue. Thanks for the input, I enjoyed the guideline you suggested, chani . PageRespiratory, there was no hummidification or HME--I did get hummidification in place--the ETT was nearly occluded with dried, thick secretions. I could barely insert the closed system suction catheter down the ETT--did end up breaking the circuit and doing the evil deed. I first got her 4 days postop, she was circling the drain--went into multisystem failure and the family withdrew support the next day. I suppose most of this is stepping on toes--I suctioned beaucoo, with plugs ect. Pt was on 10 of PEEP, PIP were in the 50's , tidal volumes were under 300 and sats were staying in the 86% range, she was on ASV. So, the course for this patient was not good--WBC maxed out at 49! lots going on with her. I can understand "derecruitment" with elevated PEEPs and worry about ALI, but this patient needed suctioning. Thanks again for your input

I just posted a thread asking if it is current practice not to suction. I have been lectured extensively by the RT's at my current hospital that current practice is not to suction, much less break the circuit. I suction, when needed all the time. I'll use the closed system if it's appropriate, I can also suction by myself, breaking the circuit and keeping sterile. I cannot imagine not suctioning when needed. I do not do this act "routinely" and feel at this point I don't need too much from them (the RT's) in the way of caring for my ventilator patients.

The most recent rationale was that "current research states that one should not suction and the circuit should not be broken". I am not a nurse that will call respiratory when my patient needs suctioning, so if it offends, that is not my purpose. Closed suctioning devises are on all vent patients here, so why not use them? I do when the situation merits suctioning. If I need to break the circuit, I also do that--they do not.

I am increasingly irritated in my current position regarding the management of ventilator patients. I am working in a small rual hospital, 6 bed ICU and have been told repeatedly by the respiratory personnel here it is no longer accepted practice to suction the ETT, much less to break the circuit to do so. The nursing staff here do not suction, they call respiratory for any respiratory issues. I have kept current since leaving the city and the large ICU's. I worked over 20 years trauma and burn ICU, and feel I have adequate assessment skills to make the judgement if my patient needs suctioning or not. This I do not simply do on a wim! I know the indications and the risks of ETT suctioning, but I do not think it is appropriate to simply leave all those wonderful secretions, mucous plugs, pulmonary edema, ect in there. I am big on turning, repostioning, mouth care, HOB elevation ect. Once in a blue moon we have a patient deteriorate into full blown ARDS. (Don't want to go into what that becomes here). I have done an extensive literary search, see nothing that states ETT suctioning is not done--I have concluded if there are secretions, they get suctioned being carefull to assess patient, ect. Also stated if needed it is "okay" to break the circuit. What is your experience lately?

All the above posts are excellent, but I am a career nurse and I just wish nursing would get off the word "care"! Just is too cutesy for me anymore. We have struggled as a profession and to this day still have a difficult time with just the definition of what nursing is. This will be unpopular, but.....I don't necessarily care ( in the sense of liking)....I deliver care. Striving for excellence in nursing--what is that?!? The word "caring" just doesn't do it for me, it just doens't fit me anymore. I offer you this--nursing to me is vigilance. For the most part, I am a priviliged observer in the worst time of people's life. It actually is a burdensome responsiblity. To some, we are a caring profession--but I don't want caring to define me anymore.

I had a very strange experince not so long ago while recerting for PALS. A video was being shown of an infant in very obvious distress--the instructor hands me this baby mannequin and says "ask a question, give a treatment or pass." I sat there for an uncomfortable peroid of time cuddling this little thing in my arms, not saying a word, untill he had to nearly pry it from me and adjorn the class for a break. My mind was sucked into a vortex--I had a complete audio and visual reinactment of a very distressing burn case involving an infant from my past. I could even smell the room! It was a time in my career I found myself completely shaken to the core, but was working fast and furious to save a life--no time to react to the flood of emotions happening inside me. Me--the nurse me, stepped up to the plate. Me--the person, was changed for life by what happened that day. So, there I am years after the incident happened, reliving it! It hurt the same. The instructor knew exactly what was happening to me. He has seen similar reactions from other nurses--not often, but it does happen. That day long ago, when it all ended, me and my wonderful crew of nurses went for "choir practice". (We went to the bar) We didn't know it at the time, but we were destressing ourselves and licking our wounds.

Any of you starting your own artlines? At my current facility this is under the realm of respiratory. Have had too many bad experiences for some reason and I want to get my hospital to get the P&P started with an instructional program for the ICU RNs.

Hi TNnursejane. I went thru burnout and didn't realize it until it was too late. I worked many years in an intense environment until my mother suffered a debiliating stoke. It was hard to be a caretaker on my days off and then go back into the trenches to work. The decision was made to put my mom on Hospice, and both my husband and I went to work for them. We were both long time ICU, burn nurses and I cannot tell you the wonderful experience we both had during that time. Needless to say it was a big change, but it was one of the most rewarding experiences I have had in my nursing life. It was a tender time for me. We are both back in a hospital environment, out of the big city into a rural setting. Sadly, there are just as many stressors and problems here as in the powder keg we left. More "politics" and disguntled employees here. Sad, but I just am not going to be part of anything that will "hurt" me again.

I need this small hospital. Coming from my background I am running to them. I want to be circled. As a nurse, I have seen Camelot once. I am looking for it again.

Flaerman, my thoughts are with you during this troubling time. As for me and my most stressful moment as a nurse--there have been way too many. I have taken pause in my career in nursing over the last two years. I relocated to a rural environment and a quieter pace. I had to. I have coded my co-workers, seen one to many hatchets in the head, the work of the knife and gun club, bad things happening to good people, the hayham that an adult can inflict on a child, "freak accidents", empalements, patients jumping out the hospital windows to their death, a patient pull out a gun and kill his nurse, heard one too many death bed confessions that to this day slip into my dreams. I could go on and on! I am one wacko quackco--call it fried or burnt out, but I have just seen too much and am paying for it now. I have become the nursing eqivilant to the TV character "House". I have worked shifts that I couldn't go home after--I had to go to the bar--we called it "choir practice". Shame, but true. So, I am growing hay with my little 89 year old dad and working in a quiet rural hospital and am having less nightmares. But, they still come.

I am a long time ICU nurse facing floating to a medsurg floor with the expectation of taking a full assignment. Just the opposite from you. PO pills--if it hasn't been IV, I haven't been given it--ever! Many ICU environments can be "balls to the wall" as I put it. I prefer the intensity, but many nurses do not. It sounds as if you have supportive management but said nothing of your co-workers. Many times this is the root of all evil. There are many threads on this forum about "eating our young". This is a tired old dance, but I still see it played out. Are your coworkers supportive and approachable?

sbadalamente, you hit the key. The CNA's at this facility are entrenched, some have worked at this little hospital 20-30+ years. They "run the floor" and believe they can make or break the nurse. Why we have to play this game, I don't know, but I just joke it aside and tell everyone they can be the boss of me and I'm the best pooper scooper this side of the Mississippi. I am somewhat of a mystery here, I don't take any lip from the Docs and many times have just been passing thru and overhead a few raking a tearful nurse over the coals publically--I just don't tolerate that and jump right in. I am a pitbull and it can either be nice or really nasty--I'm ready to play! (gloves are off in the sandbox). So, in all I'm going to be fine. I hadn't given a PO med in years until I came here--so that's my biggest concern. Having a six patient assignment with a bunch to PO's--I'll be there looking them all up till the cows come home.