Are you still here???? Yep! Wouldn't miss it!

My partner & I arm wrestled for a CRRT trauma crush patient last Friday. I had first choice the weekend before so she took him. The next highest acuity patient was in the room down the hall according to the shift charge, so I grabbed the chart and started to prep. While prepping on my patient, I noticed the neuro doc stopping by to meet with the family. The code status was downgraded from full code to DNR. My patient 'Pebbles' had a brain aneurysm that ruptured and she was not doing well after surgery. I finished my prep at midnight and went to bed. The next morning I arrived to find that she had died two hours after I left the hospital. Picking a new patient, I got report, started reprep and began to take care of a patient with a brain mass, status post surgery, ventricularostomy and ICP monitor. I learned about calibrating his arterial line and ICP line, how to monitor intercranial pressure and doing frequent neurological assessments. My patient was affable, talked a lot and was very alert and oriented to his situation. I hung several IVPB medications and took care of his needs for the day. I was able to take out his arterial line, foley catheter and get him out of bed several times to assess how intercranial pressure would be affected with increasing levels of activity. Learning about brain compromised patients is fascinating and exhausting at the same time. I finished his care plan and helped with other patients on the unit. My partner's patient had a Swann Ganz line and an expert on the line taught us about it as we looked at his monitors.

In the midst of caring for this patient, my care nurse had a patient who also had a stoke, whose family withheld treatment. In that regard, we were providing comfort measures to him. His lungs were filling with fluid, so I was able to help suction and clear his airway to ease his breathing and offer reassurance. By the next day he was gone. Two patients in one weekend. ICU is fast and furious in one respect and slow and intense in the next. The contrast in the ICU was black and white. Such differences with each patient.

On Sunday my happy patient was downgraded and I re-prepped (again) on a new admission from a motorcycle accident who had broken his femur and ribs. He had a chest tube and his leg was pointing in several different directions in a Bucks traction device (something invented in the Civil War - much like a weight and pulley system) that stabilizes the bones and joint while the patient waits for his surgeon to fix his leg. I was able to do some patient teaching on pain management using a PCA device which is a button system the patient uses to deliver his own analgesics. Assessing his breathing was interesting. When someone has a pnemothorax (collapsed lung) due to trauma, their breathing sounds like hiccups..short inspirations which are cutoff midway. I made a bath blanket splint which he could use when he felt the urge to cough and help ease the pain from his broken ribs. We talked about his surgery and a few of his friends came to check on him.

That afternoon I went to the OR with my patient and watched his surgeon prep him and open his leg at the thigh. What resembled a car (up on a jack), ended up being huge rods, nails, pins, and drilling sounds with hydraulics set against the sound of Enya playing on the surgeon's IPOD. I saw more blood with this procedure than I saw with my previous OR rotation ( thorocotomy, total neck and ventriculostomy)...the blood was all over. Everything was done with X-ray for placement so we all had to wear to protective aprons in addition to our OR gear.

In the middle of my patient's surgery, one of the OR nurses came in to grab me to help with a trauma coming in (a self inflicted gunshot victim who had severed his popliteal artery which was being held closed with an EMT's finger ETA 8 minutes)...while the room was being prepped, I sterile gloved and waited with my heart racing as to what was going to show up. (Apparently, not realizing while cleaning his gun, a bullet was lodged in the chamber, it fired into his leg...owwwie)

As they wheeled in the man, his clothing was being cut off, I grabbed all the gurney materials, clothing and bags and sorted through the bloody mess to get the patient belongings into a separate bag. Throwing the gurney back into the hallway I re-gloved and went in to assist the prep. The patients legs needed to prepped and elevated for sterile wash and possible vein grafting. I had one leg and another nurse had the other. It felt like each leg weighed about 100 pounds each. 10 minutes later, the surgeon was there, draped and cutting into the leg to secure the leg to repair the artery. The anesthesiologist was the same one I had observed with my OR rotation and I was amazed at how fast he was able to get this trauma patient under and intubated.

With the muscles in my arms still shaking from holding the gunshot victim's leg up for so long, I walked back to the other OR to check on my patient who was coming out of OR and going back to ICU. I escorted him back to the unit and with my care nurse, completed the PACU assessments in the ICU, which involves assessing all his vitals every 15 minutes, getting blood samples and cleaning him up after surgery. My patient had been intoxicated when he was injured. Earlier in the day we talked about drinking and driving. My patient verbalized how fortunate he was to be alive and that his friend (riding on the rear) had not been seriously hurt. You wonder if it is a wake up call or a pattern of risk taking that will eventually catch up to the patient. We are there to treat and teach.

As my patient woke up, he looked at me and said, "Are you still here?" "Yep!" Wouldn't miss it!

Welcome to Neuro Trauma Intensive Care... Roll with it baby

Web photo courtesy: (Hartford Hospital Images)

Excited about the prospect of critical care for the weeks leading up to it, the 4 days prior to prep were nerve wracking to say the least. We finished last semester after being in a comfort zone with theory instructors and clinical faculty that I came to depend on. You go into this learning curve which I liken to a roller coaster; already defensive, the next loop might be the one you totally barf on- because so much time, resources, blood, sweat and tears is invested into the venture of this type of learning. It can be disappointing to be treated like you haven't worked hard enough, long enough or know enough to be successful.

I went to prep as early as permitted on Friday (just knowing how slow prep can be for me). I tried to pick the most complicated patient based on the recommendations of the ICU RN in the unit at the time. Little did I realize how fast some of these patients turn over either to a step down unit, transfer to med-surg, home or sadly, to the morgue. So, I wanted someone with airway problems, perhaps some brain issues and maybe some renal stuff..so that it would be complicated enough. Sure enough, my patient had a brain bleed, he had a craniotomy and a ventriculostomy (both of these surgeries were procedures I had seen on OR rotation, so I was excited about taking care of a patient post op in the ICU. This patient had airway issues too, with failed mechanical ventilation, a relatively new tracheostomy (something I already had experience with)...and renal compromise because I saw they were doing a 24H urine collect on him and I knew he'd be around for the weekend....it was that or I was looking at taking care of a patient with a hip fracture. Been there. Done that. So, I thought I had a good one.

Knowing how much of his care was multi system, I went to my old friend (Lewis textbook) and started looking up care plans for inter cranial bleeds/increased intercranial pressure..management of trach patient and (oh, my patient was also in DTs for ETOH withdrawal, so I had resources there). What amounted to be a NANDA compliant, medication compliant (I had 7 pages of medications I had to reconcile) and also look up this patient's labs and diagnostic studies, ended up amounting to an 11 hour prep including time in the neuro ICU making sure I had all the information from his chart that weighed about 15 pounds...head home...and 8 hours at home all night. With my own brain function ceasing at midnight, I collapsed into bed, a complete insomniac, because I was trying to remember the sequence on the crash carts. Imagining I would surely be working a code (the imagination runneth). In addition I was looking at neuro trauma information on the web from allnurses.com and trying to be sure I brushed up on things in case the docs caught us off guard. We hadn't worked 12 shifts yet and this was going to be a new first this weekend. So after drifting off at 1:30, I remember I hadn't done a patho-map (the one thing I've NEVER been good at doing well)...so I went to concept mapping (saw "uncontrolled HTN")..wrote on it that it was draft and I would do a real one the next night after I met and assessed my patient. (Note: We can't show up to clinical unless we have something...I had to get up at 5 AM to be at clinical by 6:30 AM). I dropped off to sleep at 2:45 AM and the alarm nudged me at 4:45. I shot out of bed like a cannon ball, showered, gathered up my stuff and headed out the door to find an open coffee shop. With 3 shots in my cup, I got to the hospital early, met our new group in the lobby and met the first of our two new CIs (clinical instructors). We went to our assigned units. My buddy and I headed up to Neuro Trauma, to get report from the night shift and meet our care team.

My care murse (male nurse) was a staff III nurse. We had a great day. He was very experienced, had a wealth of knowledge and allowed me to ask a lot of questions. I was able to work with my patient a lot and he gave me the space to also work with the patient's family. One thing I immediately noticed was how much my patient had improved in the 24 hours since I prepped on him. His ICP monitor was out, his NG tube was out and his trach was being weaned. I was able to take out his foley catheter, get his head shaved completely..because believe me, it looks kinda ridiculous to have half your head shaved and the other lookin like Bozo the Clown. He now had a nice Daughtry-esque appearance that made him more comfortable in bed. I did my neuro assessments and head to toe assessment and watched how my care nurse charted on the new flow sheets. I gave a lot of meds, changed EKG pads (because how else could my patient be smiling and in asystole at the time) and then watched how everyone else around me adjusted to life in the ICU. It was impressive. My buddy pulled an ICP, inserted a NG and did all kinds of cool stuff on her patient who was coming off a dirt bike trauma. The hours passed and I think I got home around 8:30 PM. I had been up since 4:45 AM.

I left the shift utterly exhausted and went home to hand sketch my pathomap with colored pencils and a sketch book pad...I updated notes on my care plans pertaining to my patient, logged med reactions, made sure the lab results were updated and did my self-evalution..After all that, I went to bed at 1:30, only to get 4 hours sleep and then rush back for day 2.

Rushing to the hospital, I made it in time for report. Different care nurse. Different clinical faculty. My patient looked great. We were able to repeat a lot of day 1, activities, plus shave his face and get him bathed. My second CI dropped by to look at my paperwork and asked me a couple questions about brain hemotomas and ACE inhibitors. Not knowing too much off the top of my head (at hour 5 of 12), I went to conference with the answers and decided I liked this style of teaching and interaction. She wanted to get to know us better and allowed us to say a little bit ourselves to her. She also passed around a bag of chocolate. We went to skills lab and reviewed a few things about different types of med pumps, and looked over the crash cart again for a quick brush up. I actually left this shift totally spent ,but relieved that I survived. I liked the high acuity level, respected the nature of people's perspectives and differences of opinion and learned a lot. Most importantly, I gained my patient's trust.

On the way out the door, I stopped by the floor where my patient was moved (as he had been downgraded - meaning he was improved enough to be off ICU) to say goodbye. It was sweet to wish him well and say goodbye, plus it was rewarding to hear a little gratitude from the patient and his wife for the 24 hours we spent together. Nursing is an intimate relationship that starts and ends quickly between a nurse and patient, but leaves an indelible mark on both.

Expect anything and roll with it. I guess I just want to be a nurse.