Should an old dog learn new tricks advice form MSICU & Neuro welcome (VERY LONG )

[dorimar, BSN, RN]

So, I've been an RN since 1985 (worked the whole time). I've been in general ICU for 18 years (mix of MICU, SICU, CCU, but mostly MS ICU) in several different places over the years. What I HAVEN'T done is CVICU (fresh CABG) and NEURO/ TRAUMA ICU.

I am used to being everyone's resource on Swans, Vents, hemodynamics,labs, rhythms,CRRT, drips, assessment, critical thinking, etc. I know ARDS, sepsis, MSOF, DIC, etc. up & down. I never pushed info on anyone, but was always availbable to anyone who had a question. I always tried to make people feel comfortable to ask questions and not to feel stupid. Again, I never intruded advice on anyone but was always willing to help if asked.

I have recently decided to branch out and learn Neuro ICU (w a little unwanted trauma to boot), in a big inner city teaching hospital. I am wondering if I made a big mistake.

It has always been more important to me that I know i am doing my job well, than if others think I am doing my job well ( I go home with MYSELF @ the end of the day, not my coworkers. And I could not live with myself if I caused harm). Hence, I have been very forthright and upfront regarding my lack of knowledge in the NEURO/TRAUMA area. I have had an almost pathological fear of cervical spinal trauma's and traumatic brain injuries & missing something critical early or acutally causing harm. My orientation was rather short (3 days- and my own fault as I could have asked for more time) , I got to work with ventrics and SAHs and aneurysm clippings, which I did not fear. We have a trauma unit which gets most of the traumas, but my unit gets the traumas involving the head & the overflow traumas (these were my fears).

So, my first trauma admit, I did not know my co-workers, or who my good resources would be. It's a 17 y/o (had to be a kid!) ATV accident with closed head injury. my report was horrible (are they always so bad from the trauma bay? I was appalled). He was involved in ATV accident (no helmit) intubated on secne and flown to my hospital. No info on conciousness @ scene, or lack there of. Nurse tells me His head CT show mutiple SDH's "all over". She states his neuro assessment was: that his pupils were reactive & that he was moving all 4 extremities spontaneously, but not to command before she started propofol. She also states, by the way, that he has blood coming out of his L ear (CLOSED HEAD INJURY??) Then she tells me that Mexico place an NG tube but, that it wasn't in the right place so she manipulated it, and reinserted it and now it is putting out gastric contents ( or cerebral cortex?!!). When I asked her if they did any other scans and what they showed, she states, "I'm not sure what you're asking me. Of course we did a whole body scan, but I don't know any results except the SDH's in the cranium". Also, the computer was down so I couldn't check these results myself. So... any way, no info on his C- spine ( everyone tells me that if the CT of C-spine showed anything it would have been part of his admitting diagnosis). Of course we will keep him on C-spine precautions until cleared, but I expected to know if the scan showed anything. Then she tells me, "oh, there is an order for Mannitol 75mg iv now. I didn't give it" ( my room is not even cleaned yet by the way, so he is not coming right up). So I say,....."Oh". I ask her about any other lab results, but she knows none, because the computer is down. I stated to the other nurses on the floor, that I did not think it was approppriate to insert an NG tube with head trauma, due to the risk of basilar skull fx and cribiform fx w NG ending up coiled in cranium. 1 nurse concurred, but the others rolled their eyes at me condescendingly like i was nuts(you see, I had shown weakness, the ultimate crime in ICU).

He comes up to me sedated on propofol with GCS 7-8 (sedated or neurologic defecit?) propofol is runniing at 85 mcg's /kg/min, but I'm afraid to decrease it just yet, because his rigid c-spine collar hasn't yet been changed to softer Aspen collar which Ortho-tech is coming up to do any time ( remeber I have no C -spine CT results). He is moving all 4 extremities spontaneously to noxious stimuli only. Pupils are only 1.5-2mm and very sluggish bilaterally. NOONE said anything about SLUGGISH reaction in report.

So, anyway, I am now in a quiet panic (Deer in the headlights look on my face i'm sure). Can't even think. All that is going through my head is, "Are these pupils a neuro change?", "Is he showing signs of increasing ICP"? "Do i bring his sedation down to assess him before we change his collar?", "How the ---- do we change his collar without causing spinal cord damage if he actually did have a fx.?". I am so worried about causing him harm, that I can't even do basic nursing stuff like hook him to the monitor or set up his iv's and alines. I kid you not. I felt like a new grad. Then the ortho tech came up and told me to "hold the coconut" and I had no clue what he was talking about. I began to remove the ET tube securing device (which was some Extra-terestial device & not just tape). He states, "uhm...hold the head". I was so embarrassed & ashamed. I could not believe that I was reduced to this. So that done, I ask the team leader, " I need to bring him up hourly now to assess his LOC"? She tells me yes(makes sense to me, as i want to catch any neuro change indicating secondary injury). then very shortly he rapidly spikes temp from 98.9 to 101.2 in matter of minutes. I know that I need to get the temp under control, but am concerned that this may be a sign of increasing icp on maybe the hypothalamus or something like that (ie do i need to notfy the neuro surgeon?) So I ask the team leader, "His temp is spiking, is this something I need to call about?" (She was very patient with me I might add, & I developed a respect for her from this night, but i did not know her prior to this, and everyone else was telling me it was ok to intubate the brain w an NG tube, so I didn't trust my resources which added to my stress). She told me, "they would want you to get the temp under control". I said , "yes I know that, but should I still notify someone as it could be a sign of increaseing ICP on -say the hypothalamus"? She just repeatedly said, "you need to get the temp under control" and SHE did so with ice packs and cooling blanket (as I was in a non- functional state in my panic). No , but really i'd at least already given him tylenol , lol. Then when i woke him hourly, he of course kept getting agitated, & then 2 other nurses came in and said, "You're not bringing him up every hour are you"?!! Then he got tachycardic in the 140's to 150's ( still SR) even while sedated and receiving fentanyl. His MAP remained >80. He was putting out 450-800 cc's urine /hr (he did get mannitol 6 hours prior and u/o didn't decrease yet). I have no central line and now I'm worried about hypovolemia and maybe DI. So I get serum osmolality and urine sg & now is is time to give report.

The kid just had some contusions and was extubated the next day and sent out. I was very glad. However, that night I came very close to making a decision to go back to MS ICU. I was thinking, "I would not want ME taking care of my son in this situation, & therefore I should not be taking care of someone else's son in this situation". Since then, my neuro-surgical nursing book arrived in the mail, I have been reading non- stop and have made it a point to be in the room of the trauma and cervical injury patients with the nurses assigned, so I can learn. I have learned so much just from getting getting my book ( for which i waited a long time). Now I feel much more comfortable with the care of these patients.

Now there is the problem that everyone thinks I don't know anything about anything. I'm sure talk went all over the unit about this nurse with all the ICU experience that freaked out and can't handle a crisis.

The funny thing is, codes don't freak me out. Paralyzing 17 y/o kids does. It's wild to me to have an RT talk down to me & try to explain a vent setting, when all the RTs I've worked with in the past came to ME for help trouble shooting. Now I see nurses pass looks to each other regarding myself. It is SOOO bizarre to be in this situation. I swear I could probably teach THEM so much. I'm used to caring for high acuity patients maxed out on pressors, requiring PC ventilation, CRRT & what not.

It's ironic that now that I faith in MYSELF in this job (which is the most important), my peers have no faith in me. I have decided to give it 6-9 months, and if I haven't earned the trust and respect and if I still have confidence issues, it's back to MSICU where I truly excell. (I do hope to excell in NEURO ICU as well though).

I'm sorry this was so long. Many of you probably quit reading a long time ago. I really would appreciate any advice, or input. I am a forever learner.

Doris

[canoehead, BSN, RN]

All of your questions made perfect sense to me, and experiencednurses should be able to explain the rationale for their answers to an orientee. Are you still on orientation?

The NG tube - I'm not a neuro nurse but it seems that if they already have done a CT scan then they would know about any fractures or risk of injury before inserting the tube.

I am in agreement with you that Mannitol and information about whether the C spine is cleared should be a priority. Maybe someone else can shed some more light.

[NurseyBaby'05, BSN, RN]

It sounds to me like you did ok. It also sounds to me like you'd rather be a big fish in a small pond. Nobody wants to be the bait, but this is a chance to grow professionally. You won't know everything overnight. Who cares what your coworkers think? You are capable of doing the job. Let your actions speak for themselves.

P.S. You could only work with what you were given. The sloppy report did you no favors. The important thing is that you adapted and overcame

[dorimar, BSN, RN]

Thanks Nursebaby,

But really I didn't adapt and overcome that night. The patient did ok, but not because of me. I did however learn from the experience. As far as wanting to be the big fish, not really. I am USED to being the big fish, and sometimes this responsibility is very tiring. I was looking forward to learning and turning to others for help. I do want to be respected though (and as i said I didn't respect MYSELF that night). .It has been very ego busting to say the least (& despite what I said about knowing all I do & my years of experience, my ego has never been that big to bust). But as I said I am learning, and willing to give it some time. Many nurses seem so laid back and unconcerned now days, but I have never been this way. I have always felt very responsible for my patients and I worry about them (very type A). Consequently, i am very thorough and delv deep into their charts to find out labs, Xrays, progress, plan, history, etc. I know I am kind of a freak in this aspect (& viewed as such), but at every place I have worked, this has always been eventually viewed as an attribute to be respected. I just hope I am given the chance and not written off for my high strung tendencies.

Doris

[jax]

It sounds to me like you didn't get the support you needed. Your concerns were all valid and you obviously knew your stuff and what to look for, you just needed some support - didn't get it, and got anxious.

I think as you get to know your co-workers, know who you can bounce concerns off you may become more comfortable . Maybe it's because you are in learning mode, and you're used to being in super competent mode.

I know if I was suddenly transplanted out of my unit - I would feel just like you.

I reckon you'll do fine.

[geekgolightly, BSN, RN]

dorimar if you don't mind, can we get an update? how are you doing these days? i have always admired you here on the board, and hope that you are doing well.

[dorimar, BSN, RN]

Thank you so much Geekgolightly. I am doing fine. I didn't give the neuro unit the 6-9 months i said i would. I left after only 3 months, and i do feel kind of like a failure in that aspect. I just hated it. all the young kids with their sudden quadrapalegia, and it didn't seem to faze anyone but me. I needed to go. I just don't have the right mindset for it. I wasn't afraid of the C-spines anymore, just broken hearted by them. Also, I was never treated well by many of the staff & that makes all the difference in the world (at least to me). I did stick around long enough to see that it wasn't just me, but some of the other new people weren't treated well either. I am back to M/S ICU again, and even though it is much busier than most other types of ICUs (as usual),I am happy to be back in familiar territory. I'm glad to be back to dealing with trying to get families to accept death instead of trying to get these young kids to accept their life.

Again thank you for the kind words and thanks for asking geekgolightly.

[geekgolightly, BSN, RN]

i'm glad you did what was best for your heart and mind rather than sticking it out to prove some arbitrary point. good on you.

i'm still looking for that one good ICU unit to begin critical care nursing.

[gradcare, LPN]

Dorimar,

Too bad you bailed, I work a mix of general, surgical and neuro (see the profile). General rule of thumb for heads is if base of skull suspected NO NGT ogt. Neuro can be rewarding sure you see kids die or worse live life adjusting to the fact that they can control their head only, or parents adjusting to children that may have to go into long term care, but you also get to see kids (and older) recover from situations where you thought that they would not survive. Seems to me you were asking mostly the right questions, seems like they looked at you time in the field and decided that you didn't need orientating appropraitly. Also sounds like that unit is an abhoration. I have only seen a few neuro ICU's and they tend to be quite tight due to the sheer mental strain of what you see. To paraphrase "kay san" "and it's only other neuronurse's that undestand"

[ericuRN]

Hi Doris,

Wow, what a noc! I am an ER RN currently making a career change to the SICU. I hate to bash fellow sisterhood, but the trauma RN that gave you report.......What was she smoking? Was she a new grad? Our ED uses orogastric tubes (OG's) immediately on intubated CHI's if not already done PTA to protect the airway. If not PTA, then immediately upon the pt's arrival to the trauma bay. As for propofol, we don't use it on CHI's, so I can't help you on that one. You sound like you really know your stuff and was just a wee bit nervous about treading on unchartered territory. I am with you, though. I would definitely be concerned about the temp. Our Neuro ICU RN's have been known to be very condescending to ED/trauma staff, but on the other hand, when you get reports like you did, I can see why. Neuro ICU RN's are a breed of there own, but that isn't a bad thing. LOL. Anyway. As for me, I just gave two weeks notice, going to the ICU, so I can relate to how you feel. Good luck and hang in there.

So, I've been an RN since 1985 (worked the whole time). I've been in general ICU for 18 years (mix of MICU, SICU, CCU, but mostly MS ICU) in several different places over the years. What I HAVEN'T done is CVICU (fresh CABG) and NEURO/ TRAUMA ICU.

I am used to being everyone's resource on Swans, Vents, hemodynamics,labs, rhythms,CRRT, drips, assessment, critical thinking, etc. I know ARDS, sepsis, MSOF, DIC, etc. up & down. I never pushed info on anyone, but was always availbable to anyone who had a question. I always tried to make people feel comfortable to ask questions and not to feel stupid. Again, I never intruded advice on anyone but was always willing to help if asked.

I have recently decided to branch out and learn Neuro ICU (w a little unwanted trauma to boot), in a big inner city teaching hospital. I am wondering if I made a big mistake.

It has always been more important to me that I know i am doing my job well, than if others think I am doing my job well ( I go home with MYSELF @ the end of the day, not my coworkers. And I could not live with myself if I caused harm). Hence, I have been very forthright and upfront regarding my lack of knowledge in the NEURO/TRAUMA area. I have had an almost pathological fear of cervical spinal trauma's and traumatic brain injuries & missing something critical early or acutally causing harm. My orientation was rather short (3 days- and my own fault as I could have asked for more time) , I got to work with ventrics and SAHs and aneurysm clippings, which I did not fear. We have a trauma unit which gets most of the traumas, but my unit gets the traumas involving the head & the overflow traumas (these were my fears).

So, my first trauma admit, I did not know my co-workers, or who my good resources would be. It's a 17 y/o (had to be a kid!) ATV accident with closed head injury. my report was horrible (are they always so bad from the trauma bay? I was appalled). He was involved in ATV accident (no helmit) intubated on secne and flown to my hospital. No info on conciousness @ scene, or lack there of. Nurse tells me His head CT show mutiple SDH's "all over". She states his neuro assessment was: that his pupils were reactive & that he was moving all 4 extremities spontaneously, but not to command before she started propofol. She also states, by the way, that he has blood coming out of his L ear (CLOSED HEAD INJURY??) Then she tells me that Mexico place an NG tube but, that it wasn't in the right place so she manipulated it, and reinserted it and now it is putting out gastric contents ( or cerebral cortex?!!). When I asked her if they did any other scans and what they showed, she states, "I'm not sure what you're asking me. Of course we did a whole body scan, but I don't know any results except the SDH's in the cranium". Also, the computer was down so I couldn't check these results myself. So... any way, no info on his C- spine ( everyone tells me that if the CT of C-spine showed anything it would have been part of his admitting diagnosis). Of course we will keep him on C-spine precautions until cleared, but I expected to know if the scan showed anything. Then she tells me, "oh, there is an order for Mannitol 75mg iv now. I didn't give it" ( my room is not even cleaned yet by the way, so he is not coming right up). So I say,....."Oh". I ask her about any other lab results, but she knows none, because the computer is down. I stated to the other nurses on the floor, that I did not think it was approppriate to insert an NG tube with head trauma, due to the risk of basilar skull fx and cribiform fx w NG ending up coiled in cranium. 1 nurse concurred, but the others rolled their eyes at me condescendingly like i was nuts(you see, I had shown weakness, the ultimate crime in ICU).

He comes up to me sedated on propofol with GCS 7-8 (sedated or neurologic defecit?) propofol is runniing at 85 mcg's /kg/min, but I'm afraid to decrease it just yet, because his rigid c-spine collar hasn't yet been changed to softer Aspen collar which Ortho-tech is coming up to do any time ( remeber I have no C -spine CT results). He is moving all 4 extremities spontaneously to noxious stimuli only. Pupils are only 1.5-2mm and very sluggish bilaterally. NOONE said anything about SLUGGISH reaction in report.

So, anyway, I am now in a quiet panic (Deer in the headlights look on my face i'm sure). Can't even think. All that is going through my head is, "Are these pupils a neuro change?", "Is he showing signs of increasing ICP"? "Do i bring his sedation down to assess him before we change his collar?", "How the ---- do we change his collar without causing spinal cord damage if he actually did have a fx.?". I am so worried about causing him harm, that I can't even do basic nursing stuff like hook him to the monitor or set up his iv's and alines. I kid you not. I felt like a new grad. Then the ortho tech came up and told me to "hold the coconut" and I had no clue what he was talking about. I began to remove the ET tube securing device (which was some Extra-terestial device & not just tape). He states, "uhm...hold the head". I was so embarrassed & ashamed. I could not believe that I was reduced to this. So that done, I ask the team leader, " I need to bring him up hourly now to assess his LOC"? She tells me yes(makes sense to me, as i want to catch any neuro change indicating secondary injury). then very shortly he rapidly spikes temp from 98.9 to 101.2 in matter of minutes. I know that I need to get the temp under control, but am concerned that this may be a sign of increasing icp on maybe the hypothalamus or something like that (ie do i need to notfy the neuro surgeon?) So I ask the team leader, "His temp is spiking, is this something I need to call about?" (She was very patient with me I might add, & I developed a respect for her from this night, but i did not know her prior to this, and everyone else was telling me it was ok to intubate the brain w an NG tube, so I didn't trust my resources which added to my stress). She told me, "they would want you to get the temp under control". I said , "yes I know that, but should I still notify someone as it could be a sign of increaseing ICP on -say the hypothalamus"? She just repeatedly said, "you need to get the temp under control" and SHE did so with ice packs and cooling blanket (as I was in a non- functional state in my panic). No , but really i'd at least already given him tylenol , lol. Then when i woke him hourly, he of course kept getting agitated, & then 2 other nurses came in and said, "You're not bringing him up every hour are you"?!! Then he got tachycardic in the 140's to 150's ( still SR) even while sedated and receiving fentanyl. His MAP remained >80. He was putting out 450-800 cc's urine /hr (he did get mannitol 6 hours prior and u/o didn't decrease yet). I have no central line and now I'm worried about hypovolemia and maybe DI. So I get serum osmolality and urine sg & now is is time to give report.

The kid just had some contusions and was extubated the next day and sent out. I was very glad. However, that night I came very close to making a decision to go back to MS ICU. I was thinking, "I would not want ME taking care of my son in this situation, & therefore I should not be taking care of someone else's son in this situation". Since then, my neuro-surgical nursing book arrived in the mail, I have been reading non- stop and have made it a point to be in the room of the trauma and cervical injury patients with the nurses assigned, so I can learn. I have learned so much just from getting getting my book ( for which i waited a long time). Now I feel much more comfortable with the care of these patients.

Now there is the problem that everyone thinks I don't know anything about anything. I'm sure talk went all over the unit about this nurse with all the ICU experience that freaked out and can't handle a crisis.

The funny thing is, codes don't freak me out. Paralyzing 17 y/o kids does. It's wild to me to have an RT talk down to me & try to explain a vent setting, when all the RTs I've worked with in the past came to ME for help trouble shooting. Now I see nurses pass looks to each other regarding myself. It is SOOO bizarre to be in this situation. I swear I could probably teach THEM so much. I'm used to caring for high acuity patients maxed out on pressors, requiring PC ventilation, CRRT & what not.

It's ironic that now that I faith in MYSELF in this job (which is the most important), my peers have no faith in me. I have decided to give it 6-9 months, and if I haven't earned the trust and respect and if I still have confidence issues, it's back to MSICU where I truly excell. (I do hope to excell in NEURO ICU as well though).

I'm sorry this was so long. Many of you probably quit reading a long time ago. I really would appreciate any advice, or input. I am a forever learner.

Doris