Last night a patient stop breathing on us. Twice. I had 20 minutes left in my shift and just got back to the unit from transporting another patient to the floor to find Jena, one of the PACU nurses, with the Ambu bag over Mr. Code Blue's face. Ambu bags crudely but purposely channel oxygen to those in need. Think of it like a billow you pump with your hand attached to a mask over a person’s mouth and nose.
.The following is a play-by-play of everything that happened over the next hour, along with the mental score I was tallying for myself. To keep an honest score I have to rewind the story to roughly 20 minutes before I ran my transport. Jena was busy doing some charting standing over her patient. I was sitting at the nurse’s station in a chair watching her work and looking at her patient. I noticed the patient doing what seemed to be shivering or slightly shaking. Shivering and being cold after surgery in and of itself isn't abnormal. The operating rooms are cold and anesthesia, intravenous fluids, and open incisions can lower body temperature 2-4 degrees Fahrenheit. But for some reason, something didn't sit right with me or look right to me. I’m giving myself 1 point for noting the nursing spidey-sense that all was not well, and I’m going to award a bonus point because this was the first time I’ve ever had that sensation which was pretty cool. Unfortunately I lose these points right back to the house because a neglected to tell Jena what I saw or that I felt something wasn’t right. Alex: 0, Self-Doubt: 0 As soon as I got back to the unit and saw the Ambu bag in use, I obviously knew something was up, we don’t bust those out for a good time. The patient had de-satted while I was on my transport. This means that Mr. Blue’s blood was finding less and less oxygen to load and deliver to the rest of the body. The intensity in the room elevated a notch. Linda, the other PACU nurse working, was scrambling for some medication and yelling some instructions to me. She told me make a couple phone calls, one to the OR (operating rooms) informing them that we needed some help with their most recent delivery, and the other to the floor Mr. Blue had departed from for surgery to let them know their patient was not coming back. Jena had been getting him ready for transport while I had been away. Thank goodness this all didn’t go down on the transport! Alex: 2, Self-Doubt: 0 The anesthesiologist who had worked the procedure on our friend came to join the party. After a brief pow-wow, the conclusion was reached that the narcotics given to the patient had probably impacted his breathing. Narcotics slow the rate and depth of breathing which can lead to a respiratory depression where not enough gas exchange is taking place and carbon dioxide levels in the blood rise while oxygen levels decline. This is obviously not a good sign since we are not plants. Luckily Linda had already been keen to this train of thought and had been grabbing the proper anti-narcotic drugs while yelling at me to make some calls. The drugs worked and the patient began to rebound. We were joined by the intensivist and after another pow-wow, the conclusion was reached that the same thing would happen again as soon as the anti-narcotic drugs wore off. It was decided the best course of action was to intubate the patient and put him on a ventilator. The anesthesiologist left and came back with the intubation kit and called for a syringe. Jena asked me to grab it for the anesthesiologist and scurried off to do something I should have already been moving on. Luckily the anesthesiologist asked for another syringe and I got redemption to quickly grab another one for her. Alex: 1, Self-Doubt 1 While everyone was setting up to do the intubation I was watching the monitor and watched the patient begin to de-sat on us again, 95%, 90%, 85%, 80%,78%... For some reason I figured that because there was two doctors and two nurses present, I didn't need to say anything about our patient taking a nose dive south right in front of us. Fortunately the anesthesiologist looked at the monitor, “Oh Gosh, he’s de-satting!” By now we’d been joined by 2 respiratory therapists and they began to bag the patient again with the Ambu bag. Alex: 0, Self-Doubt 2 The anesthesiologist is ready to start intubating the patient. I brought the crash cart over just in case things decided to get even worse. The anesthesiologist wanted a CO2 monitor to attach to the airway, but we couldn't locate one in our supplies. Everyone thought there was one in the crash cart so I opened up the crash cart but we couldn’t find the CO2 monitor in the intubation drawer. I remembered that there was another crash cart on our unit so I busted into that one and pulled out the CO2 monitor they're looking for and handed off to the nurse. Unfortunately I didn't realize that our other crash cart was just for pediatrics, so now we have to crash carts that need to be reloaded. One of the respiratory therapists then chimes in that the CO2 monitor is in the miscellaneous drawer of the crash cart. One point for me making moves, but minus ½ a point for unknowingly trashing our PEDS crash cart. Minus 2 points to the respiratory therapist who could have helped us avoid that whole debacle. Alex: .5, Self-Doubt: 2 The anesthesiologist began the intubation. I immediately felt foolish because everybody was asking for things and I had no idea what they're asking for. The anesthesiologist wanted a wand to suction then she wanted the tubing which was right in front of me… Alex: .5, Self-Doubt: 3 In the end the patient was stabilized, intubated and placed on a ventilator, which is all that really matters. We had one other ICU patient on our unit who it turns out the respiratory therapists had come down to help me transport to the ICU. I began switching her over to a transport monitor and went with the two respiratory therapists to deliver the other patient to the ICU. It was a good transport. Everything went well and I felt very helpful, which is saying something. ICU transfers used to be overwhelming because there are a lot of lines and connections to the patient to keep an eye on and a lot of people working and helping with moving the patient from the cart to the bed. Sometimes it was hard to know where to jump in and help. Alex: 2.5, Self-Doubt: 3 I got back to the unit from the transport and honestly felt a little sheepish that I hadn't been able to do more with everything that had happened. Jena and Linda both told me thank you for all the help and Linda told me I was going to be a great nurse. But because I sometimes beat myself up, I wondered if she was being sarcastic. I felt like maybe I don’t have what it takes to be a great nurse or to work with critical care and trauma patients. Linda kept telling me to leave, because I had ended up being at work an extra hour when it was all said and done. As I scrubbed out and walked to my car I reflected on the shift. I realized I could get down on myself for everything I didn't do or look at everything I learned tonight and grow from there. I learned if I see something, say something (this logic is probably more effect in the hospital then on the CTA) and act even if you are the lowest person on the totem pole. I learned what a whole bunch of new equipment was. I learned what happens or what we do when a patient stops breathing. I learned how fast things can turn south for a patient. I learned we have a PEDS and an adult crash cart. I learned that my sharp eye for detail can be just as strong with patient care. Alex: 3, Self-Doubt: 1 There’s so much I don’t know, but I also am not even an RN much less an anesthetist. My co-workers tonight all have many years of experience on me, and they too probably felt like a bumbling fool at some point when they were green and cutting their teeth in this profession. The RNs on my unit often ask me about my school studies, and I’ve heard on more than one occasion that while school is great, you won’t remember or use much of what you learn in school. Medicine is a career that you have to learn by actively engaging in the work in addition to what you study and learn. I’ve always been blessed with the book smarts, and am grateful to walk through some knocks last night to be more prepared for whatever comes next. I’ll be ready.
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Alexander McNaChronicles of my journey into the nursing profession. Archives
September 2018
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