lilredrn

Average 40s-50s on my unit. I'm one of the young 'ens and I'm 35!

Running the code: There is a pecking order. If the intensivist is in the unit and available, they run the code (Place ETT, CVC, etc). It is their turf after all If unavailable, the ED doc will run the code and consult the hospitalist. ED MDs are proficient in placing ETTs and CVCs as well. The hospitalist may run the code if they feel comfortable as well (not as common in my hospital - they have their hands full!). If ED MDs and intensivists are not available, we may need to contact anesthesia for ETTs and CVCs for the latter. All hands on deck: Every available staff RN in the ICU shows up (save one for watching monitors / call lights). Recorder: One RN charts (Generally this is the house supervisor). Meds: ICU dedicated pharmacist shows up with their tackle box of code meds (awesome because they'll mix drips on the spot!!!) Or one RN gets meds out of the code cart. Another RN pushes meds. Another RN manages drips. CPR: everyone else circulates doing compressions. RT bags the patient. Hs & Ts: If possible, the patient's assigned staff RN stays out of an assigned position to discuss what might have precipitated this event and to comfort the family. Auxillary staff: If we're lucky we will have on auxillary staff member to help out as a rover. If not, whomever is managing drips and scanning meds can run for supplies as needed. We are all ACLS certified in my unit and have "mock codes" annually during a scheduled shift. They are are called overhead just like real code blues are and all appropriate available staff respond. Our ICU charge generally ends up running the code. Pretty empowering. We get feedback on things like the quality of our compressions, time from code to start of compressions, etc. Our nurse educators go out to all of the hospitals in our hospital system to do these mock codes. It is a good learning experience. We honestly don't debrief as often as we should post-code.

We just opened a stepdown ICU at our hospital, and now our M/SICU acuity went up. We still take all the vents (even home vents), super-resistant ETOHers, and vasoactive gtts. Even with the increase in acuity, I really like being able to go more "in depth" into my knowledge and understanding of the patient and the pathophys... and I won't lie, the adrenaline rush of the code or finding the one thing that keeps the patient from coding is my drug. On the other side, I have heard that the 3:1 pt ratio of the stepdown patients (AKA "soft ICU" patients) is far more frustrating. When I am the admit bed in my unit and have only one semi-stable patient, I make it a priority to have someone watch my patient for a few so I can go visit the stepdown unit and offer a second pair of hands. I could not sanely do what they do!

I wish I could make this happen for my patients who have a poor prognosis, but this creates much anxiety for their loved ones. Often they ask for the patients to be transferred to a medical floor or to a SNF to die. I think they want to feel like they did everything they could. You know, I wish our society didn't view hospice as the "grim reaper." They provide such compassionate care and really do an amazing job facilitating the most comfortable death possible, with as much dignity possible in the most comfortable surroundings.

You are so sweet to post this for all of us. The job market is still very tough here on the West Coast. How is the job market over there? Is it still tight too?

As a relatively new nurse to ICU, I wish more nurses on our unit would discuss issues like quality of life and futility of treatment. I've only been there for 5 months and have yet to see these subjects addressed by nurses. From what I have seen, it is discussed by the doctors in a very clinical, factual way and nurses step back and stay out of it. Nothing against doctors, but we are the ones who are with them 24/7 and they learn to trust us and talk to us. I just don't see the rationale for placing an ET tube in a patient with end stage lung disease that is an adamant DNI. We can't fix the irreversible structural damage that has taken place and the patient does not want to be vented. Does this make me ethnocentric? I have held family members while they mourn the loss of their loved ones and can understand them wanting to do everything possible. But in my opinion, sedating and venting a patient takes away precious few last days that could be spent at home with family saying goodbye. These patients are mentally altered after we wean them off the benzos, even if they do fly after we extubate them. We add to this delirium with all of our noisy machinery, unfamiliar environment, and by going in and waking them up repeatedly, turning them, emptying their foley hourly all hours of the night, etc. Don't get me wrong, if they are actively dying, I am not ever in a hurry to discharge my patients to die at home unless the patient or patient's family wants them home. It is an honor to be there and take care of them and their family during this milestone in life. And yes, I cry right along with them. My previous job was working in an assisted living facility with 180 patients by myself on night shift as a new grad RN. I had 3 resident assistants that helped me care for this huge patient load. There just weren't enough of us to go around. Especially if I had a hospice patient. It broke my heart. There is no way I could give morphine q15 minutes and care for the other 179 patients. I really felt a sense of guilt when I got my dream job and left that facility. I worried about whether or not my patients would get the care they needed. I guess this leaves me wondering, is there any one best place to die?

Congrats!!!! Yeah!