Saturday, September 20, 2014

My placement rocks!

Finally got a moment to post about placement. The hospital is ginormous! I couldn't believe how big it is. My hospital is BIG.... this one trumps it almost three fold! It's amazing. I found out it's about 15 years old, so it terms of newness, it's pretty new (IMO).

I saw some pretty cool things. Didn't do much myself until the last day there. I put in three foley catheters and discontinued one as well as an IV. Nothing spectacular but at least I can check it off my clinical skills checklist. Oh and I did a TON of EKGs so now I feel pretty confident about doing them myself. At my hospital we have a tech that does them all. I was thrown into the lions den with those the very first day.

Day one was pretty awesome, there was like 5 traumas in like a 4hr period of time. The first one was the best. Maybe I'll write about it another time. HIPPA might come back to bite me in the ass because it's an interesting case so I need to figure out ways to change details to get around it. I did get  involved on a little one who was dropped and suffered bilateral skull fractures..... the poor little one cried the ENTIRE time... I mean, I would too.... I'm pretty sure he/she was experiencing a pretty terrible headache.

Another person we sort of dropped into our lap. We were floating in the unit and were doing something to help another person when my preceptor Anna noticed that a fellow nurse was running towards CT with a patient and knew that something bad was going down. So she called for me and off we went running to help. Well it turns out that their pt was having a seizure when the chief complaint they cam in with was COMPLETLY different.... as in they were classified as a NSTEMI and when they were questioned further told the nurse & Dr that they also had a headache with hypertension and so the doc wanted to clear this person's head..... just in case it was something else!

Well good thing they were already on their way there.... too bad this pt wasn't protecting their airway very well. Completely non responsive. Got an emergent CT scan and the oxygen level remained high enough that an emergent intubation wasn't required at that point. We were able to get the scan and found the pt had a subdural /ventricular bleed... neurology was pretty sure it was an aneurysm that burst. While they were trying to get a scan with gallium for a more definitive determination, the pt started to come back neurologically and respond to pain and shortly after that to voice. We then moved him/her to trauma bay "just in case".... good thinking!

Neurology decided that they wanted him/her to be put on a cardene drip to control the BP to be <140 systolically... well for those who don't know, you have to wait 15 min after starting to know what the response will be on the BP. Well the BP dropped from a SBP of 150ish to 103.... not a good thing so we paused it. And for the next 15 minutes, we hung out in the trauma bay while different hospital services came and did their assessments. We let the spouse come in and sit and chat during this time. The doc also came in and talked to both of them to find out what their wishes were for treatment and such.... good thing, especially considering what was to come!

The pt was complaining about how their chest and their head was killing them... I asked a couple of people for orders for a pain med. It's not fair to the pt to stay in pain (IMO) but I wanted something that wouldn't strew neuro findings (as a narcotic may). Because the pt had soiled themselves during the previous seizure, we also took the time to cleam them up. And we also put a foley catheter in because we knew that the pt was sick and would need close monitoring.

After we were done, the pt asked if they could sit up some so we put them at a 60 degree angle from about a 15 degree and didn't do so quickly, but simple took our time. Then not even 2 minutes later the pt started SCREAMING about how their head hurt and that it was "stabbing" so my preceptor went out of the trauma bay and I dropped the head back flat because I figured that THAT was why there was a change.... then the pt stopped responding and had a tonic seizure right in front of me while I was trying to do a neuro assessment. Lost consciiousness and was super rigid. Before this happened, I had given her a mouth swab to wet the mouth and tongue since we wanted the pt NPO (nothing by mouth).... mouth swabs were cleared by the doc though provided they didn't swallow. So when the seizure happened they clamped down on it and I had to pry it out of the mouth. Then I ran to the door and yelled that the pt was having another seizure.

Then a code was called so that the necessary people come running and I swear, 20 ppl arrived in like a minute! It was quite impressive. One of the residents that was involved in this case during the original seizure came to the head to try to protect the airway. I was at the head of the bed and was responsible for monitor. I did another BP and it was now 198/130 (I know the top number but I kinda forget the bottom one.... though most often we generally care only about the top one anyways).... so that was quite shocking. We turned the cardene drip back on, this time higher than it was originally while the docs got situated. During this early phase the spouse was still in the room (OMG right!) and I made contact with them to try to let them know it was going to be alright and that we had things covered. At some point the spiritual care person took the spouse out of the room and comforted them.

In the meantime the pt's heart was going crazy and doing all different (very bad things) such as torsades which then progressed to 2nd degree heart block (FYI this one can lead to cardiac arrest) so out comes the code cart... all while other people are pulling up meds to intubate. THANKFULLY her own heart cardioverted back to a normal rhythm (probably because of the cardene drip) so we could focus on intubating... which went without incident.

Then things calmed down a bit and a lot of the people left the room, and we proceeded BACK to CT to get another scan.... which showed a progression (we kinda figured that though). And then we brought th pt back to trauma and by then neurosurgery made their decision about what they were going to do.... they were going to do a "bolt".... which means that they were going to do a ventriculostomy - drill into the pt's brain to stick a tube in to drain some of the fluid off the brain while measuring the intracranial pressure (ICP). I stayed pretty darn close since I'd never seen it before.

Unfortunately the pt was a fighter of the propofol and started to move when neurosurgery was making meaurments so I was asked to go under the sterile field to hold the head in the correct plane. Well it's a good thing that I kept my hands there because there were several times where the propofol amount wasn't enough and required more.... in a one hour period of time the pt recieved 400mg!!! As well as Versed.... so it was shocking that this person kept trying to move. We also put restraints on - just in case.... good thing for that because I'm sure that the pt would have pulled the ET tube out or at least broken the sterile field.... bad things either way!

It took a bit for the bolt to go through the dura but once it did you could immediately tell the pressure in the pt's brain was extreme because the fluid came out immeasurably though once the bolt was in a tube was threaded through and then hooked up to a measuring device that was based on gravity to draw the fluid out. Immediately 18cc was taken off which is a SUPER high amount. But you could tell that the fluid that was draining wasn't just blood but cerebrospinal fluid AND blood mixed. The closest comparison I can explain it to is serosanguinous fluid.

We eventually got the pt stabilized enough to take to ICU. Boy was the entire thing from start to finish crazy though! I must say, I can't wait to go back!

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