I am beginning to see that in nursing, schedules and plans are never firm. It turns out my preceptor in the ER isn’t ready for me yet so I have spent this week in the ICU. As anxious as I am to get to my ER training, this week has been incredibly enlightening for me. I see the value of being oriented to the different units and getting a feel for how they work and what their challenges are. It will help me be more understanding and better prepared to transfer patients there from the ER.
On my first day I hit the ground running. I met the nurse I would be working with as we were receiving a patient from one of the medical floors who had come in through the ER the night before. This patient had come here from Mexico a few days earlier to celebrate his birthday with his nine children now living in CA. He came into ER with pneumonia and abdominal pain and was admitted. Then his labs came back showing he had a raging infection and his lactate was 6.0 and PPT of 107! Yikes he was going into septic shock. CT scan of his abdomen showed stones in his common bile duct and the MD’s suspected ascending cholangitis. When he arrived on our unit his blood pressure was in the 60’s and his extremities were cold and cyanotic. Our first task was to get fluids into him fast. He had one IV running Lactated Ringers which we turned up to 1200cc/hr, and quickly got another large bore line started, more lactated ringers 1200cc/hr. At this point the room was swarming with residents and an attending, all trying to get an arterial line started so we could measure his blood pressure internally which is much more accurate. The main goal being to keep his organs perfused to prevent organ failure. The poor patient was stuck numerous times since the blood pressure was so low it was hard to get the art-line in. They all kept asking for supplies which I would run to find, BUT it was my first hours on the floor I didn’t know where stuff was kept, OR the code to get in the room! I caught on quickly though and soon was grabbing supplies, opening sterile packs, handing out 4×4’s and tape, and most of all trying to comfort the patient as he was being poked and prodded. They finally got the arterial line in, and we got some blood gases drawn and set up the pressure monitoring. We hung two units of FFP to help his clotting, and more fluids. They also started a levophed drip which can raise blood pressure after fluid replacement in hypotensive shock and a versed drip, and IVP fentanyl to sedate him for the procedures, He started to have some fluid in his lungs as they were about to take him to radiology for an ERCP, so they intubated him and put him on a ventilator. I was able to go to the ERCP and observe. The MD found the stones blocking the bile duct and flushed them out, releasing a slew of pus and debris. Then it was back to the ICU, next a central line and a foley catheter. The central line used was a special one called a presep catheter, it has a fiberoptic tip to allow measurement of SvO2, or oxygen saturation which is important to measure in sepsis. By this time it was 10pm and we were starting to see some improvement in his blood pressure and hoping he was out of the woods. He hadn’t produced any urine yet, due to some kidney failure and we were quite worried about that. As we gave report to the night shift and reflected on the evening I really saw how the nurses and MD’s work well together, everyone stayed focused and helped each other as we worked. The residents and attending MD discussed the plans and procedures in detail so I learned a lot just listening in and observing. It felt great and exhausting to be part of the process. I hope this patient improves through the night and that tomorrow is calmer.