Ykes! The PICU!

Posted
by SnarfGirl SnarfGirl Member

Specializes in Home Health, Med/Surg.

Well, I'm in my final semester of school. Finals are on April 10th. It's so close! I've had a pretty good clinical experience thus far, minus a few nurses who have been less than helpful...but yesterday I was in the PICU for the day and my head is still spinning at how fast everything can go wrong!

I don't have intrest in Peds - and yesterday confirmed it...it's too much. I think it takes a very special person to want to do PICU nursing and I admire them. The nurse I had yesterday was amazing - he was so kind and incredibly smart and wonderful with the patients. I felt completely inept and like a moron acutally. I will spare all the details leading up to the incident ...

But it was a good day, things were going well, I helped a 15 year old kid with Muscular Distrophy who was there for pnuemonia "cough" that was new to me. The RT showed me how to do it, and it was working! I would "cough" him, then suction, cough, suction...etc...this went on for an hour. Finally his Sats were 9o% and he was going to sleep for a while. Right at lunch he had another spell of secretions blocking his airway, and sats were not good. The RN did some deep suction, and that seemed to help. That was at 12noon. We got him on the bedpan and when he was done- he started gasping and had airhunger like crazy -looked at me and said "I'm going to die" I'm like OMG...I looked at sats and they were 80%. The RN turned the O2 all the way up. Nothing. Still 80%. Called the NP and MD in the room and they said lets get him on the BiPap. This was 1208. By this time he had gone from a totally respectful appriciative kid, to fighting, gasping, cursing and lip smacking and making very strange sounds, he was totally confused. Blood Gases taken, CO2 through the roof, and pH 7.13. Yikes! I'm thinking to myself, this kid has tons of secretions that he cant get up -why would we put him on BiPap, it just pushes it down the airway more....even then his sats were still only at 84%. By 1230 they decided he needed to be intubated. His jugulars were about 1/2 inch thick and pounding, pulse at 180, BP 70/50 and he was totally blue, nail beds and everything...he was very combative and his last words to me were "I hate you. F** YOU!" . . . I was scared he was going to die. His father walked onto the unit right in the middle of this- and he was a wreck...on the phone earlier the RN had told him he was doing well, and would go to Gen Peds later today....**gulp** I was kind of a fly on the wall at this point, holding or doing anything then asked me to do. I felt like an ass because I didn't know where anything was because it was my first day on that unit, so I couldn't even run for supplies! So they get him paralyzed and sedated and they asked me to bag him. I've done this before but I was having a trouble getting a good enough seal on his face. Finally I got the hang of it - his sats were finally at 94%. Then out of nowhere the NP who was going to tube him just yells out to someone else "get over here and bag him! You, move!" OKaaaayyy. I know things were tense, and I didn't take personal offense to it - but I felt so helpless. I didn't really know what I was doing wrong - his sats were up to 94% and his chest was rising and falling just fine. So after that I basically just watched as they tried to tube him 4 times and because of his different anatomy they couldn't get it. Sats are now at 60% and it's 12:45 ish. 5 times a charm and the MD got him tubed, the sats still didn't go up more than 87%. NG tube placed, Vent going - and BP keeps dropping. The MD I can see is getting very nervous- and decides (with consent of dad) to put in femoral central line. The juggulars are still huge and pounding, this kids heart was so stressed. I got to see the central line go in, had a front row seat for that. They got the central line in, and meanwhile had 500ml bolus of LR going into peripheral, and Dopamine on the Central line. Now it's like 1:30. Drew more labs, got a x-ray, sats still less than 90%. X ray comes back and the ET tube is 3 cm above the clavicals. NICE. No wonder his sats are still low. His anatomy was so strange that the tube woudn't go all the way down... I had to leave for post confrence at 2pm. So I did not get to see if he ever got better:cry:. The NP and MD were not hopeful that he was going to get better either. I woke up first thing this morning thinking about that kid and how fast he turned bad. I appriciate my child more now than ever. And my hats off to PICU nurses. I could never do it. I just thought It would be good for me to share about the day and get it off my chest. It was a very sad day, but a great learning experience at the same time. . . . OH - and never EVER say "boy it's quiet up here". The nurse about strangled me when I said that - and so of course it was all my fault that 15 minutes later this kid goes down....:o (not really, but it was kinda wierd that it happened that way). The MD joked when I was leaving that I wasn't allowed back.. lol.

NotReady4PrimeTime, RN

Specializes in NICU, PICU, PCVICU and peds oncology. Has 25 years experience. 16 Articles; 7,358 Posts

I'm really sorry you were made to feel like you were in the way. None of that was your fault and you don't deserve to feel like you failed in any way. You learned several important lessons though. Such as people are in intensive care because they could go sour any minute without any warning. This is especially true for kids. What likely happened with this kid is that he "threw a plug" or moved around a glob of really thick secretions that he had no ability to move again.

You now know that people in a pre-arrest state will have behaviour changes, and the next time you see that happening for no reason, you'll call for help.

You learned how to use a cough assist device and will be able to use one in other situations without needing instruction. You might even find yourself in a situation where you suggest it be tried- and do the patient a big favour in the process.

You've seen a central line placed and now know what some of the uses of these are.

And you validated something about yourself that you already knew... peds is not for you. Perhaps ICU is not for you either, because these things happen with adults too. What you described is a fairly typical day on an ICU. It's why I continually advocate for appropriate staffing and appropriate assignments. On our unit, this patient would probably have been assigned to one of our junior nurses... and trust me when I tell you that their experience would have been very similar to yours.

This young man already had several strikes against him; kids with certain types of muscular dystrophy, even now, have a shortened life span. They are prone to respiratory infections due to muscle weakness and ineffective airway clearance; the muscle weakness also contributes to the development of significant scoliosis which only further compromises their respiratory capacity. They aspirate due to poor control of their swallowing. Several weeks ago our unit had a similar patient who'd had a spinal instrumentation. He developed severe SIRS (you might need to look that up) and we spent much of that first night just keeping him alive. He got 9 litres of fluid while progressing from dopamine to epinephrine to norepinephrine before we got his BP in a good spot. The nurses on that night were all highly experienced and we all felt the same pressure to perform. While it's unlikely that this boy will survive to see his 30th birthday, he's still alive and living his life NOW because of our care.

SnarfGirl

SnarfGirl

Specializes in Home Health, Med/Surg. 100 Posts

I'm really sorry you were made to feel like you were in the way. None of that was your fault and you don't deserve to feel like you failed in any way. You learned several important lessons though. Such as people are in intensive care because they could go sour any minute without any warning. This is especially true for kids. What likely happened with this kid is that he "threw a plug" or moved around a glob of really thick secretions that he had no ability to move again.

You now know that people in a pre-arrest state will have behaviour changes, and the next time you see that happening for no reason, you'll call for help.

You learned how to use a cough assist device and will be able to use one in other situations without needing instruction. You might even find yourself in a situation where you suggest it be tried- and do the patient a big favour in the process.

You've seen a central line placed and now know what some of the uses of these are.

And you validated something about yourself that you already knew... peds is not for you. Perhaps ICU is not for you either, because these things happen with adults too. What you described is a fairly typical day on an ICU. It's why I continually advocate for appropriate staffing and appropriate assignments. On our unit, this patient would probably have been assigned to one of our junior nurses... and trust me when I tell you that their experience would have been very similar to yours.

This young man already had several strikes against him; kids with certain types of muscular dystrophy, even now, have a shortened life span. They are prone to respiratory infections due to muscle weakness and ineffective airway clearance; the muscle weakness also contributes to the development of significant scoliosis which only further compromises their respiratory capacity. They aspirate due to poor control of their swallowing. Several weeks ago our unit had a similar patient who'd had a spinal instrumentation. He developed severe SIRS (you might need to look that up) and we spent much of that first night just keeping him alive. He got 9 litres of fluid while progressing from dopamine to epinephrine to norepinephrine before we got his BP in a good spot. The nurses on that night were all highly experienced and we all felt the same pressure to perform. While it's unlikely that this boy will survive to see his 30th birthday, he's still alive and living his life NOW because of our care.

Thanks for the encouragement! I actually found it to be somewhat exciting (in a wierd way) I just wish I knew more....instead of being a fumbling student...I know I'll get there some day. And you are right- I did learn that PICU is not for me, just because it's kids...but for some reason I think I might like adult ICU more. I start that rotation in 2 weeks and I'm looking forward to it. By the way he did have Herring Rods also, r/t the scoliosis.... I hope you will continue to advocate for appropriate staffing, had that kid not had the nursing staff he had - who knows what would have happened. . . Thanks again!

NotReady4PrimeTime, RN

Specializes in NICU, PICU, PCVICU and peds oncology. Has 25 years experience. 16 Articles; 7,358 Posts

I'm glad I could give you some perspective. PICU really isn't for everybody and I wish more people would recognize that sooner. I believe that to be a good PICU nurse, you really have to love it. But it sounds as if you learned something else about yourself and that is that you are able to think through critical situations. If you choose ICU later, that will be a valuable asset. Nobody says you can't be Jell-o after the fact, but if you can keep your head and do what's necessary in the moment, you'll do great.

I will continue to advocate for adequate staffing, at least for now. I'm feeling more than a little burnt out these days and feel like I'm the only one who's willing to stand up and say what needs to be said. I have arranged a meeting between front-lines staff and management for a couple of weeks from now and have been encouraging people to come and air their own grievances but I fully expect that I will be the only front-lines nurse there. Again. And I'm telling people now that if I don't get some support, I will stop listening to their beefs and they can live with it.

(BTW, they're Harrington rods...)

SnarfGirl

SnarfGirl

Specializes in Home Health, Med/Surg. 100 Posts

I'm glad I could give you some perspective. PICU really isn't for everybody and I wish more people would recognize that sooner. I believe that to be a good PICU nurse, you really have to love it. But it sounds as if you learned something else about yourself and that is that you are able to think through critical situations. If you choose ICU later, that will be a valuable asset. Nobody says you can't be Jell-o after the fact, but if you can keep your head and do what's necessary in the moment, you'll do great.

I will continue to advocate for adequate staffing, at least for now. I'm feeling more than a little burnt out these days and feel like I'm the only one who's willing to stand up and say what needs to be said. I have arranged a meeting between front-lines staff and management for a couple of weeks from now and have been encouraging people to come and air their own grievances but I fully expect that I will be the only front-lines nurse there. Again. And I'm telling people now that if I don't get some support, I will stop listening to their beefs and they can live with it.

(BTW, they're Harrington rods...)

Yes...Herrington Rods....I knew something didn't sound right there :icon_roll

Good luck with the meeting - it takes good nurses like you to really get something done. If I were in the PICU I'd want people like you taking care of me or my child. Thanks for your insight, and I learn something more about myself everyday I am in clinicals, and I really think that one of these days I will be a darn good nurse . . . just going to take time..

NotReady4PrimeTime, RN

Specializes in NICU, PICU, PCVICU and peds oncology. Has 25 years experience. 16 Articles; 7,358 Posts

Thanks for the support.

I know you're never going to stop learning, about caring for others, knowing and caring for yourself and making choices that work for you. The day we stop learning is the day we should quit. We'll never know everything and it's a waste of effort to attempt it, but we can know a whole lot! You will be a darned good nurse, I feel it.

SnarfGirl

SnarfGirl

Specializes in Home Health, Med/Surg. 100 Posts

Thanks so much!

live4rachael

live4rachael

134 Posts

What a very crazy day for you as a nursing student. Kudos for surviving and keep it up!

As a parent of a child who was in a similar situation (she passed away in a PICU after having similar experiences though only 7 months old; she had Spinal Muscular Atrophy - a type of MD), I still remember what those days were like, Cough Assist and BiPap and suction and sats that won't maintain. And those nurses, God bless them. I remember so many of them and their passion, their drive, and their true love in taking care of mine and all those other kids. I didn't understand how they did it, but now am excited to help others eventually, though I've got a long ways to go (I'm in semester 1 of 4).

If you are sure you don't want peds, then kudos for you on knowing about yourself. That's half the battle. It sounds like you've got the makings of a great nurse.

SnarfGirl

SnarfGirl

Specializes in Home Health, Med/Surg. 100 Posts

Thanks for the kudos. I am sorry about your baby :crying2:

Trust me those 4 semesters will go by very fast - good luck!

live4rachael

live4rachael

134 Posts

Thanks, you too!

I appreciate the condolences. Sweet Rachael (hence my username) is who motivated me to be a nurse. I started nursing school 3 years to the day of when she passed (tell me that was a coincidence...)

SnarfGirl

SnarfGirl

Specializes in Home Health, Med/Surg. 100 Posts

Just thought I'd pass on that the patient I refered to in my original post died after I left :cry:. I found out when I went back today...I am glad he's not suffering anymore but I feel bad for his family. The RN said they chased him all day and the rest of the night but he just couldn't maintain resp and BP no matter what they tried. He finally coded and they were unable to get him back.

Is it strange to be glad that he went and doesn't have to suffer....it's a very confusing feeling. I'm sad, yet relieved he doesn't have to live the way he was....

live4rachael

live4rachael

134 Posts

Sorry to hear the news but I think your confusion is right on. It shows your concern for the patient's well-being. Of course you're sad but the not suffering is a bit of relief.

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