Whirlwind Day
I just finished week four of my new job. I'm a new grad in the SICU but am precepted so each morning I willingly take whatever patients they think I can handle. I feel like I've been handling each day well, some days are smoother than others, and I have been getting positive feedback from my peers. There haven't been any tears yet and I haven't been overly stressed or too overwhelmed....until yesterday. It was one of those days where you don't get a break for breakfast, you don't get lunch until 1400, and you're even farther behind when you get back. I know everyone has had a day like this so you all can relate. But as a new grad this is the day that I had been waiting for since I started four weeks ago. The day that made me ask myself, "What am I doing here?" Here's how it went:
I get report on my two patients and am immediately overwhelmed. My one patient was in an MVA. She has list of eight or more surgical procedures that I don't fully understand, she was transferred from different hospitals and different floors, she's ventilated and sedated, has spine and leg precautions due to multiple fractures and a recently pulled lumbar drain, a large draining abdominal wound, blood clots all over and a recent PE so she's high risk for another one (yikes), and all the other complications that come as a result of these conditions. She's my age so I feel exceptionally sorry for her. Residents and surgical teams come in asking questions that I don't have answers to. Another resident asks me to turn down her propofol to wake her up. "Ok turn it down some more...ok just turn it off and tell RT to switch the AC to SBT and see how she does on her own." Meanwhile, I try to print an EKG strip but the machine is out of paper. Figures. My second patient is being discharged home, uncommon from the ICU; orders were in by 0715. The APN walks in mid-report handing me the discharge papers. I haven't discharged a patient yet so I'm clueless. And the patient keeps desating as he drifts in and out of sleep because he refuses to get treatment for his undiagnosed OSA. I am a deer in headlights by 0730. Little did I know... it was just the beginning.
By 0800 the residents and RT are ready to extubate but I need to order a morphine PCA first, which through Sentac the pump can take an hour to get. So in the meantime I went to discharge this other patient and get him out of the way. I had to give his 10 plus medications but of course some were missing, some where never ordered, some he didn't want to take. I never got his morning glucose and he had just finished eating. Crap...insulin is one of the meds that were never ordered. Ugh, now what? Ooops, RT is calling me to the other room to proceed with extubating, sans PCA pump. I drop these meds mid-scan and run into the other room where I'm greeted by family who are asking how long the extubation will take and how long she's going to be in pain since I don't have the PCA. RT, hold on, let me give her a bolus of dilaudid before you extubate....um, ok, looks like we're already starting. Sorry, I'll get her dilaudid as soon as I can. Hopefully she's still feeling relief from the fentanyl bolus earlier. Keeping in mind her spine precautions I can't sit her up in bed to avoid aspiration or help her breathe so I hope she does ok lying on her back. Phew, she does fine. I suction the gunk out of her mouth and throat and we're on our way. Go get that dilaudid. Oh yea, I need to discharge that other guy. He needs his meds and is probably on his way to DKA after eating that big breakfast without his insulin (ok, not really). Give the dilaudid, answer more questions from the family, reposition the patient's leg a little to the left, more to the left, too far go back to the right. I go back to discharge this other guy. Oops, time for rounds! I'm too overwhelmed to hear everything as the team discusses her case outside the room. I write myself a long list of new tasks to do. I quickly request the new heparin drip from pharmacy knowing it will take a while to receive. Now back to this discharge. I pull his two IVs and art line that take forever to clot because of his blood thinners. Fifteen minutes later I review the discharge forms with him and call for transport. Back to my other lady who is doing well. Heparin still hasn't arrived. Whoops I didn't do any I&O for the last two hours. It's ok I'll just divide up the urine for each hour. I still haven't looked up any of her surgical procedures so maybe I can take a minute to look it up now. Pull up computer, check the MAR and oops, I need to give her morning meds. Oh, and I never got the post extubation blood gas. I go to draw the blood for the ABG but I can't draw back on her art line. Mid-struggle I get a phone call from the charge nurse saying transport is here but my discharged patient is gone. "Oh, I think Lauren wheeled him down, sorry I forgot to tell you." Back to this ABG. It's still not drawing back. What the heeeeccccck. Put blood draw on hold. The PCA pump arrives (finnaaalllly) but now my preceptor is gone so I can't hook it up. I can't get anything done! At that same moment the residents walk in and want to change out her cordes to a triple lumen. "Is now a good time?" he asks. Ha! "Suuurre," I say with a smile and sweaty palms. So now I need to switch out her central line drips over to a peripheral IV...that she doesn't have. I call in help to put in an IV ASAP. The first IV infiltrates. Grrrreeaaat. I call back in another nurse to help me with a second IV. Resident comes back as I'm in mid-panic mode saying we will postpone the procedure due to a clot in her right atrium. Oh, good, I can relax. But oh no...is this her inevitable PE that's bound to happen on my shift?! I shake my head with a mix of fear and dread. "Keep on truckin'," I say to myself. I push her IV meds, I finally hook up her PCA, call for the heparin again and finally get that going. My preceptor troubleshoots her art line and draws her ABG. I move around her pillows, push them in, pull them out, push them in, get the hair off her neck, suction her throat, wipe the spit off her face, and readjust her leg a little to the left, more to the left, back to the right, and carefully tuck in the sheet around her toes because she likes to feel it. She's finally comfortable. Phew. I have a minute to chart. Nope, the resident walks back in and says he is cleared to rewire the central line despite the clot. "Is now a good time?" he says again. "Sure," I say again with a smile and still sweaty palms. I take a big deep breath for my sanity. Ok let's do this. I switch out her central line drips to the new PIV that's working beautifully, but are all these drips compatible? I pause for a minute to look them up in clinical pharmacology as the residents are shifting her bed around and removing the pillows, which of course shifts her leg and her back and untucks the sheet from her toes. *thanks a lot* Mid procedure I have my mask on and I'm helping with supplies when my preceptor comes by and asks, "How are you doing? Do you think you can take an admit?" *nervous chuckle* "Umm...really?" I about died! One look at my face and she knew, "It's ok, you can take it after lunch, I'll be here to help you." Another deep breath. *Sigh* I finish helping the residents, move the bed back, fluff her pillows, adjust her leg to the left, more to the left, back to the right, tuck in the sheets between her toes and chart my assessment. It's 1400. Off to lunch I go...right as the admit arrives. Man! How many more things can I not get done today? Forget it, Lauren can do the admit (she did offer, after all), I'm going to lunch and I'm taking my time!
After lunch I have a quick meeting with my manager who tells me I am exceptional and no one believes I'm a new grad. Wow...could that reassurance have come at a better time? That quick talk gave me a second wind and the motivation to get through my day with a smile. Back into my lady's room to check on her and see what else popped up on my To Do list while I was away. Time to change out all the tubing and drips after rewiring the central line, more blood draws, figure out how to hang all four antibiotics at the same time, change her saturated dressings, fluff her pillows, adjust her leg left, left, then right, tuck in the sheets, etc.
I was in that room the rest of the day. I never made it into my new admit's room. Luckily my preceptor is awesome and reassured me that she knew this one patient was enough to handle and didn't push for me to take on the second patient. "Thank you so much!" Before I knew it it was 1915 and the night shift was ready for report. I spewed out as much as I could to the night nurse, encouraged the patient to keep her head up and keep fighting, and thanked the family for being so good to her. I walked out of the room taking another deep breath and smiled. I did it (without tears!). Phew. I did it.
