It's been 4 hours since I got off work and I can still feel the throbbing in my feet. I started off the night with 1 patient and ended up with two...a fresh post-op that turned into an open cholecystectomy because the gallbladder was gangrenous. He was fine though, it was my first patient that was tough. Arguably the sickest guy on our unit but my favorite type. Intubated, sedated (every ICU nurse's dream haha). Being able to have a patient that can't talk is sometimes such a blessing. Ok, I know what you're thinking, so hang in there with me. I promise I am not as mean as I sound. haha
This is what I love about intubated patients...
I get the time to focus on every little detail of their physiological state. I have a chance to really tune in and pay attention to their baseline; to read their reactions and to take the time to try and make them comfortable and I can do this without any distractions. I can spend time talking to family and giving them comfort in a time that is usually incredibly frightening and overwhelming.
When I have a patient like I did last night, they usually have multiple factors that are keeping them in the ICU. For example, my patient had aspiration pneumonia, alcohol withdrawal, liver failure etc. He was on two IV pumps worth of pressors, insulin, fentanyl, versed etc. To make a long story short, physiologically there is a ton to manage with patients like this and on top of that there is a person underneath that diagnosis (or diagnoses in most cases).
This is what I love about working in the ICU, with intubated, sedated, extremely sick patients. It forces me to think about the big picture. (Also what I LOVE about cardiac patients) You have to take every body system into account.
His pH is 7.24, CO2 is 65....hmm we might want to adjust the frequency on his vent? What do you think? (usually what I say as a hint to the intern)
Ok my fresh post CABG is crashing with MAP's in the 40's, systolics in the 60's. He's on 3mcg of Dopa, and 0.1 of nitro....neither of those are to be touched...by request of CT surgery. Well we can start a phenylephrine drip but thats risky with a fresh arterial graft and if he has a CVP of 4...and his urine output has been minimal...well, clamping down on his vessels and not perfusing the kidneys is prooooobably not a good idea. He obviously needs fluid. Especially if his cardiac ouput is low but yet his SVR is fine.
Ugh, I love it. I love having to figure out the puzzle of my patients. Taking every system into account and collaborating with people to create a better outcome. Really, I think people underestimate what nurses know and have to study to get to where we are. Especially working in critical care, the learning curve can be pretty great and the examples I gave are so basic! There is always so much to learn and when you have people who are willing to teach and learn and figure it out with you....it's the best feeling in the world. It's challenging and that's what I love about my job.
Then there is that other side of nursing. The side that is able to step back from seeing the patient as just a diagnosis. This, 95% of the time is what new doctors...(and sometimes maybe the experienced ones) often miss.
For example, my patient from last night was on a ventilator setting that is called CMV. Controlled Minute Ventilation. To put it briefly, everything is controlled by the ventilator. Breathing is forced in and your respiratory rate is fixed, how much you breathe in, how much oxygen you get, how much air is left in your lungs after you exhale....all of it is controlled by the ventilator. You have to have the patient sedated on this type of setting because it gives no room for the patient to take his own breath or breathe at his own rate. It is incredibly uncomfortable for someone to be awake, with an ET tube down their throat on this vent setting. Seriously, picture me putting an ambulation bag over your face and forcing you to hyperventilate.....not fun.
Well, the intern who had him today tells me to turn off all of his sedation. When I asked why, his answer was, "We need to have him do a few things for us."
Obviously he needed to do a neuro check, and he must have assumed that I, being a nurse, wouldn't know that was the reason for turning off the sedation. I see the reasoning for it because you need to know if the patient could wake up and follow commands...an important factor when considering whether the patient can be extubated or not. The Intern didn't realize that I had come across this situation before.
At this point I'll spare you what I was thinking and just tell you what I said. :)
"So, you want me to turn off all of his sedation while he is on 100% fiO2 on CMV, so you can do a neuro check?" I try to give him a chance to explain, hoping there is something I've missed.
"umm, well.." the intern begins to stammer.
"You guys aren't planning on trying to extubate are you?" I spared him the trouble of answering my previous question.
I know this isn't even possible but sometimes....you just never want to assume anything in a teaching hospital, plus I'm still trying to hint to the intern that I don't agree with him.
No such luck for me....the intern was obviously very upset that a nurse was arguing with his orders. I could tell because his eyes were rolling so far back into his head I thought he was going to pass out.
At this point I realize that there is no point arguing, so I smile, and nod and I nicely say, "Ok, well I will be giving report to the day shift nurse in a few minutes and I will let her know."
Luckily, one of my old preceptors is taking over this patient (I was so busy they split up my assignment and had two people take care of what I did alone...hence the feet throbbing) and when I tell her about the conversation she looks at me, laughs and shakes her head.
"I know, but you know C. I'm just the nurse and I'm the young nurse so I figured I'd let you fight that battle. My feet hurt and I want to go home."
"Ok, honey, go home and get some rest. I'll just bring it up on rounds when the attending comes in." C. pats me on the back.
When I came back that night, I went up to C. and nodded towards our patient, "Did they end up turning off the sedation?"
"Nope." she says with a smile that had "you should have listened to the nurse" written all over it.
I have a feeling that intern learned a good lesson that day.
I love being an ICU nurse because it is the perfect balance of science and art. It is helping others to remember that there is a person in that bed...not just a diagnosis. Not just a way for you to impress your resident or fellow or attending. It is not just a learning experience or a lesson for you during your 1 month rotation in the place that I work everyday. There is so much to consider and if you would take one moment to listen to me, you would realize that much of what you cannot learn from the patient...you can learn from the nurse that has just taken care of him for the past 3 nights in a row. I'm not a parent but I can only imagine if I'm this protective of my patients....I'd be a force to reckon with as a mom. haha.
And after all is said and done, tired or not, heard or not, it's worth it if it means I have made a difference in my patient's day.