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CICU, Telemetry
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CCU BSN RN has 7 years experience and specializes in CICU, Telemetry.

5 years in Cardiac Surgery Stepdown 1.5 years in Cardiac Intensive Care

CCU BSN RN's Latest Activity


    Feeling incompetent after rapid response

    If you don't work in an ICU, and you don't have more than 3 years of experience.... You did MORE than I would have expected you to be able to do. You identified that longer pauses/lower HR than previous was an issue, checked the patient's blood pressure and evaluated your patient, and got your charge nurse and notified/got the physician to bedside. Heck, you even put pads/leads on and got the defib and/or code cart and atropine. Believe me, your charge nurse would have wanted to know about the change in your patient's acuity level right away even if you felt like you had it covered. Plenty of nurses I've worked with on telemetry have experienced this and failed to realize it was an issue that required immediate action. Plenty still have not told their charge nurse (me) and made me feel like a real idiot when an RRT is called and I didn't even know anything was going on. Needing a few other people to help out when your patient deteriorates quickly are the reason that we have charge nurses, rapid response, and code teams in the hospital. Even in ICU and with 10 years of experience you won't be able to transcutaneously pace your patient, give atropine, get an EKG, and communicate with the team all by yourself. You just simply don't have 8 hands and 4 brains.

    Covid-19, No Beds, Ugly Stuff

    I'm a little concerned about the concept of a hospital that doesn't own a ventilator or Bipap machine, to the point where I'm having trouble getting past being incredulous about that and actually wrapping my head around your issue. How big is your hospital? Do you have operating rooms? What happens when your ER doc does intubate the patient prior to transfer? Do you have to wait until EMS is at bedside to intubate so that they can be placed on the ambulance's vent? Do you just sit there and bag them until EMS shows up to transfer the patient? What if your patient has OSA and is on Bipap every night at home? They either bring their own machine with them or they're out of luck? I literally just have hundreds of questions about this logistical nightmare.

    COVID-19: No PPE!!

    If I actually followed our hospital's 'donning and doffing' guidelines every time I entered a COVID room: 1. We would be out of gowns and gloves 2. My patients would be dead, because their levophed would be paused for the 4-6 minutes it would take me to reach the 'upstream occlusion' alarm. And that's 4-6 minutes if I'm right there and catch it right away. Usually I'm in another of my 4 ICU patient's rooms, and don't notice until their SBP is 50. So yeah. I sanitize my hands. I wear a mask and eyewear at all times while inside of the walls of the hospital. But the rest of the PPE guidelines at my hospital would mean hundreds of deaths, and I'm not willing to do something I feel would be akin to murder just because a hospital administrator teamed up with a hospital lawyer to determine how to avoid legal responsibility. Finally, to clarify, if there are adequate time and resources, and if I'm going in to a room to touch a patient or provide any direct care...of course I'm following our policy to a T. But if each of us wasted 120 gowns a shift for trips into a room that are so short we sometimes hold our breath if we don't have an N-95 nearby...nobody would be happier or safer.

    Stressed out - high potential for error in critical care

    I've been in ICU about 5 years. I'm still anxious about messing up and killing someone. I'm less anxious about it now that I have some experience under my belt, but you're at a difficult level of experience right now. You're getting more competent, which means you can appreciate how many ways in which a simple error could cause irreparable harm. You likely used to only understand about half of these ways. Sometimes ignorance really can be blissful. I find it helpful to remind myself that our unit has a very good spirit of teamwork, and any time your patient becomes more critical and starts alarming to high heaven, bleeding profusely, having life-threatening arrhythmias, etc....you wind up with at least a couple of colleagues coming to see what's going on. And if you've missed something, they're pretty good at asking appropriate questions and rapidly determining what you've overlooked or might have messed up, and then helping you fix it. Also, even though it's not very kind to admit to, I like to remind myself of things my colleagues have messed up before, which often horrify me when I hear about. Because if my colleague bolusing an entire bag of insulin or letting their chest tubes clot off didn't kill the patient....well, patients can be hard to kill sometimes. Even when they're very ill. Your body really WANTS to stay alive. It's full of compensatory mechanisms that allow people to have a heart rate of 30, or a SBP of 60 or a sat of 57% for awhile before they actually croak. That said, sometimes a swift breeze could take your patient out. Finally, if you quit and your colleagues are more short-staffed, mistakes will be made and more people will ultimately have poor outcomes. You WILL ultimately make mistakes, whether you're made aware of them or not. We're all human. Just try not to make the same mistakes multiple times. To recap: 1. Mistakes are human, patients would die without the ICU, you're providing a service with a net positive outcome, even with occasional mistakes. 2. Humans are hard to kill (mostly) 3. A little anxiety is helpful, a lot of anxiety is crippling and deserves therapy and/or meds. 4. An adverse event is very rarely exclusively YOUR fault- there are many members of the healthcare team, as well as the nursing team.
  5. I believe VERY strongly that we'll just be injected walking into work one day. That's probably how we'll find out there is a vaccine, is a surprise needle. And I also think that's the proper choice (mandatory vaccines for health care workers and honestly, for all of the American public). Even if the vaccine is terrible, unless you have a life-threatening allergy to components of the vaccine, it should be mandatory. This disease has been such a strain on our healthcare system and myself and my colleagues personally, as well as on the global economy. I'd like to see a vaccine aerosolized and pumped through the ventilation system at Wal Mart, personally. Any vaccine reactions, no matter how poorly made the vaccine is, will pale in comparison to the death and destruction we're seeing from COVID-19. Also by the time a vaccine is available in mass numbers in the US, it's entirely possible that Trump will no longer be POTUS, just as food for thought. It should be a bipartisan effort to provide for the greater good and prevent hundreds of thousands of deaths.

    COVID-19 ICU, The 12 Commandments for Front Line Clinicians

    Thank you for the advice that it's okay to drink, cry, and mainline benzodiazepines (as prescribed, of course) as needed, and that you've also seen more death this year than in your whole time in ICU. Felt like it was just my hospital for awhile there.
  7. Things like 'Team Nursing' would work so much better if I'd ever met the members of my 'Team' before I was expected to work on a team with them and appropriately delegate patient care tasks to them while also managing a criminally unsafe ICU assignment with 3-4 intubated, proned, paralyzed patients on multiple pressors. Because I barely had time to ask what unit they came from before I was being pulled in several directions to put out dumpster fires in every single room. If they were given ANY training about where supplies/meds were kept, titrating ICU drips, or if we were able to spend half an hour together so I could in-service them before assuming care of anybody...I could make it work infinitely better. Unfortunately, at least at my institution, there were 2 separate entities: the administrators writing endless policy upgrades on zoom meetings at home, and the nurses trying not to feel like they committed a murder secondary to criminally unsafe staffing. These 2 entities had no contact with one another, and thus no administrators were willing to acknowledge or change policies/procedures based upon how poorly the rollout was going.

    What is a reasonable nurse: patient ratio in ICU?

    Proned patients were always 1:1 before COVID. Paralyzed patients on multiple pressors were always 1:1 before COVID At the beginning of COVID, intubated COVID patients were 1:1 Once we had too many intubated COVID patients to staff at that level, it was basically 'anything goes'. I had up to 4 intubated, proned patients on multiple drips in the COVID ICU for several weeks in a row. They got abysmal care. Many died. We were told to be ready to take 6 COVID ICU patients. We were occasionally provided with untrained nurses from other care areas who were unable to give ICU meds, titrate drips, touch a ventilator, or really do anything terribly useful. The question isn't 'what should the staffing level be?' it's 'how criminally unsafe is my hospital's COVID ICU compared to others?'

    Switching to CCU

    I like how managers make it sound like they're doing YOU a favor letting you skip a residency. They don't want to[ have to pay for you to do a resodency. If you feel like you could go back to PCU tomorrow and still be competent...fine, skip the residency. But if you feel you've been away too long, advocate for whatever training you cann get. Worst case scenario is that you're mildly bored.
  10. CCU BSN RN

    Developing knowledge

    I picked up a copy of Marino's ICU book, and Cardiac Surgery Essentials. Also a CCRN review book if you don't have that. But I learn best by reading, so...know your style. We don't all read textbooks for fun, and that's okay. Also, ask 'why?' At work if you don't understand why we're treating a patient in a specific way/with a specific med. If you word it right, most attendings are happy to teach and most residents are happy to say some of the most ridiculously incorrect things, and laughter is good for the soul.
  11. CCU BSN RN

    med surg RN to cardiac step-down

    Pick a floor where you like the manager. And where the ratios seem good, e.g 1:3 for stepdown and 1:4 for telemetry. Don't trust a manager to tell the truth about staffing. Ask other staff when you're shadowing. You've probably learned good time management in med/surg, but you've also probably learned how much it cuts down on your stress when you have good staffing for a shift. In terms of making you more attractive to an employer...good attitude, hard worker, not over-confident. Good recommendations from your current co workers to prove you play well with others. We can teach you everything you need to know academically...we just want you to be a team player and receptive, and just generally not a jerk. Bring your best attitude to work, if nothing else. You've got some good suggestions above about topics to brush up on. I'd say the most important things are the ones that are such emergencies that you won't always have time to look stuff up....3rd degree heart block, symptomatic bradycardia, SVT, rapid a fib, and of course ACLS algorithms. Just knowing how to treat these things immediately and be comfortable with the involved meds (how fast to push, normal dose ranges, contraindications, what to expect)
  12. CCU BSN RN

    Thoughts on a new grad RN going straight to ICU?

    I'd say nurses are pretty evenly split on this. Both sides have valid arguments, and the only way to know if you'll sink or swim is to jump in and find out. Sure, you can stack your odds with a good manager, adequate staffing, a good unit culture, a long orientation/residency peppered with classroom training, but at the end of the day, it's still a gamble. The one thing I'd keep in mind is that the margin for error in ICU can be very small. Making wrong decisions, waiting too long to ask for help or page a doctor, not noticing a problem for an hour or two, failing to correctly prioritize your tasks...Yes, plenty of patients have slim odds of survival no matter what you do, but the ones we CAN save...its really hard to make sound clinical judgments right out of school and have the critical thinking necessary. It absolutely eats at you and can really mess you up when you have those cases where you feel like it's your fault someone died or had a bad outcome. It's a lot of responsibility to bear for a new grad. I've known young women who have killed themselves or gotten out of nursing entirely within a year of starting in ICU. And to be fair here, I've known a few who coped well and did fine. But that miserable year or two in med/surg or tele or stepdown...its not that you need to learn to be a great med/surg nurse, you're honing critical thinking and assessment skills, learning how to tell when a patient is in serious distress and about to crump, and how to cope with a job that is often going to try to beat you down. Aggressively. And you're doing it on a unit with generally lower acuity so that the margin for error is larger. In general, patients outside of ICU can be ignored for 30-60 minutes without dying. You can take a beat to decide how to handle something, or to think about WHY their BP is running low or they're febrile or tachycardic or whatever it is that's going on. You'll see plenty of high acuity events almost no matter where you go, I promise.
  13. CCU BSN RN

    Doctors offended by TV show about nurses

    In nursing school, like, 10-12ish years ago we had an assignment to find the most accurate portrayal of nursing on TV. Way less options since streaming was in its infancy then. But...Carla on Scrubs. That's what networks need to go for. Hard-working, knowing how the healthcare system works, and training all manner of residents all while providing good patient care. Also there is a wonderful sound byte in early Grey's Anatomy where Dr. Sloan orders Alex and Izzy to do pressure ulcer dressing changes all day. One of them asks if the nurses can just do it. His response 'but nurses are nice, and smart, and already good at their job'
  14. CCU BSN RN

    pvcs bigemy medsurg

    Basically the take home here is that all cardiac patients should have telemetry while they are ill enough to require a hospital level of care. For everyone's safety.
  15. CCU BSN RN

    pvcs bigemy medsurg

    It sounds like you have the abilities for telemetry on your unit but not in your patient room. It's true that NSR at 80 with bigeminy could read as 160bpm, or atrial flutter where your flutter waves have a high amplitude so they're all triggering the count. Either way it sounds like this person was a cardiac patient of some kind pre-op, and may need a higher level of care postop due to this kind of issue. I'd want the tele tech to compare this patients ectopy/rhythm now to the last 12-24h and see if any of it is an acute change. Again, if your patient feels fine and his vitals are stable, it means you still have time to figure it out.
  16. CCU BSN RN

    RN's skipping vital signs

    I would go find the CNAs or techs or nurses or whoever is actually doing the taking of the vital signs. I would tell nursing leadership you want to have a meeting or an in-service with them so that y'all can get on the same page and have some face time. I would bring snacks. We love snacks. Bagels or donuts and coffee are always a hit, and cheap. The people actually doing the work may not understand which patients vitals are a priority to you and why, they may not understand that vitals at 6am in bed are different than at 10am in a chair. They may not know that they should try harder not to let a specific patient refuse vitals because you're adjusting medications and they could be doing something unsafe for the patient and your license. They may have staffing concerns or not be able to see the patient's orders, just doing what the RN tells them to. The timing of vitals may be due to constraints on their schedule at certain times of day. Find out what their barriers are. Really listen. Remind them that they're an important and valued part of the patient's care, and that you all got into this to help people and to work as a team. Just my 2 cents. Management will send them a nasty email to follow orders better and then wash their hands of the issue and hope you get satisfied or that you find something new to care about. Nothing will change, you'll be frustrated, etc.