Note for the civilians: There's going to be a lot of snot talk so if it grosses you out...ya might want to stop here. :-)
Caught a Bipap pt right at shift change. The basic problem was a nasty LLL pneumonia. Breath sounds were very diminished except in the pneumonia base where they were non-existent. The RT who had him before me ran a gas, not too shabby except the guy wasn't oxygenating. Duh. Right? She moved him down from an upper floor to a lower floor right at shift change so he was completely new to me, his RN, and her charge RN.
He came down on a NRB satting 90....shit!
The RN took one look at him and said "I don't like the way he looks. He should be in a unit." I walked in and the first thing I said was "I don't like the way he looks. He should be in a unit."
We immediately went to get him on the Bipap (CPAP setting) but he FREAKED out and wouldn't tolerate the mask. The RN loaded him up with valium so he could deal with it. GReat. I got the mask on him on nothing settings: 7 of CPAP which means nothing since that's only physiologic peep but he was still cruising at 91%--on 100% FiO2--on CPAP. Okay. I talked the patient through it and prayed for the Valium to kick in NOW so he could tolerate the mask as I pumped him up to 15 of Peep but it still required 100% to keep him satting 91%. Hmmmm.....that's not right. That's a real mismatch, right?
I talk to the RN. The RN says she'll call the doctor when she gets caught up. I go to the charge nurse. The charge nurse, whom I've known and worked well with for a long time now, goes to see the pt and comes back saying "I don't like the way he looks. He needs to be in a unit."
No shit.
So instead of later the doc got called NOW and I stood around waiting so I could say my piece. When it was my turn to talk, I told what I'd done, how much O's I was on and said "I've got nowhere to go here. This guy is going to crash soon." He asked "What do you think?" I said "I'd really like to snow him and tube him, obviously." The doc said he'd send the residents over immediately.
They did come over immediately and they said they'd seen him earlier in the day and he hadn't been as bad. We were packed up and transporting to the unit inside 20 minutes. GREAT.
I gave report and wandered back to my other pts. About a half hour later, I went back up to MICU to get a soda (vending outside the unit) and check on pneumonia guy. He still wasn't intubated!!! The residents had tried a couple of times but they couldn't get it. The RT in the room said "Glenna, can you help for a minute?" Sure. So I put my soda down...and bagged for her while she took over the blade. I, being myself, jacked with the residents and male nurse and said "Girls rule; boys drool, show them how it's done." Sonovabiotch if it didn't go smooth as silk. I got the guy into perfect sniffing position, she slid the mac in, said "I see 'em", the tube went down, I pulled the stylet, and we were done.
Rock-freakin'-ON!
Before we could dance our we're so cool dance, though, I said "Are you sure you're not in the stomach because something's coming up the tube." She said "I'm sure" at the same time one of the residents said "I've got strong breath sounds" and we'd all seen the CO2 monitor change colors....we all stared and suddenly got it. I grabbed the ballard but in the time it took me to get it between the tube and ambu the grosses green foulest-smelling goo was nearly at the top of the tube. Totally the most disgusting secretions I've ever seen. Not pseudomonas green, just icky infection green. We suctioned and we suctioned and we suctioned and we suctioned and we suctioned some more. And then SUDDENLY his sats shot up to 100%. At one point during the suctioning I said "Why am I doing this? I only came up here for a soda." The residents both laughed and gave me shit aobut being in the wrong place at the wrong time if I wanted to be lazy and not have to work.
The guy had been so loaded down with secretions he didn't even sound rhonchous. It was like the never ending horror house of slime in this guy. Girl RT suctioned every little bit for several hours to get this guy cleaned out. But once he was cleaned out and she switched over to Bi-vent (Servo vent) then she was able to wean him down to 30%. Rock on! Beats the shit out of 100%, doesn't it?
It was bad but here's the deal. I love it when it all comes together in a very good way so that it's a great intervention for the pt and morale-lifting teamwork for us. I have no doubt that had we not intervened when we did we would have coded that guy on the floor. Instead of a sad turn out the guy should be fine. We got him what he needed when he needed it and he should be fine. I love it when it all comes together so beautifully. It was a win for the patient, the most important, but it was also a win for us and the residents personally to be there hands-on, and a win for our dept showing the residents that they can count on us to take care of their patients.
Today was definitely one of those days when I walked outside to the sun coming up and I thought "That was a good night's work. I love my job."
Note for the civilians: There's going to be a lot of snot talk so if it grosses you out...ya might want to stop here. :-)
Caught a Bipap pt right at shift change. The basic problem was a nasty LLL pneumonia. Breath sounds were very diminished except in the pneumonia base where they were non-existent. The RT who had him before me ran a gas, not too shabby except the guy wasn't oxygenating. Duh. Right? She moved him down from an upper floor to a lower floor right at shift change so he was completely new to me, his RN, and her charge RN.
He came down on a NRB satting 90....shit!
The RN took one look at him and said "I don't like the way he looks. He should be in a unit." I walked in and the first thing I said was "I don't like the way he looks. He should be in a unit."
We immediately went to get him on the Bipap (CPAP setting) but he FREAKED out and wouldn't tolerate the mask. The RN loaded him up with valium so he could deal with it. GReat. I got the mask on him on nothing settings: 7 of CPAP which means nothing since that's only physiologic peep but he was still cruising at 91%--on 100% FiO2--on CPAP. Okay. I talked the patient through it and prayed for the Valium to kick in NOW so he could tolerate the mask as I pumped him up to 15 of Peep but it still required 100% to keep him satting 91%. Hmmmm.....that's not right. That's a real mismatch, right?
I talk to the RN. The RN says she'll call the doctor when she gets caught up. I go to the charge nurse. The charge nurse, whom I've known and worked well with for a long time now, goes to see the pt and comes back saying "I don't like the way he looks. He needs to be in a unit."
No shit.
So instead of later the doc got called NOW and I stood around waiting so I could say my piece. When it was my turn to talk, I told what I'd done, how much O's I was on and said "I've got nowhere to go here. This guy is going to crash soon." He asked "What do you think?" I said "I'd really like to snow him and tube him, obviously." The doc said he'd send the residents over immediately.
They did come over immediately and they said they'd seen him earlier in the day and he hadn't been as bad. We were packed up and transporting to the unit inside 20 minutes. GREAT.
I gave report and wandered back to my other pts. About a half hour later, I went back up to MICU to get a soda (vending outside the unit) and check on pneumonia guy. He still wasn't intubated!!! The residents had tried a couple of times but they couldn't get it. The RT in the room said "Glenna, can you help for a minute?" Sure. So I put my soda down...and bagged for her while she took over the blade. I, being myself, jacked with the residents and male nurse and said "Girls rule; boys drool, show them how it's done." Sonovabiotch if it didn't go smooth as silk. I got the guy into perfect sniffing position, she slid the mac in, said "I see 'em", the tube went down, I pulled the stylet, and we were done.
Rock-freakin'-ON!
Before we could dance our we're so cool dance, though, I said "Are you sure you're not in the stomach because something's coming up the tube." She said "I'm sure" at the same time one of the residents said "I've got strong breath sounds" and we'd all seen the CO2 monitor change colors....we all stared and suddenly got it. I grabbed the ballard but in the time it took me to get it between the tube and ambu the grosses green foulest-smelling goo was nearly at the top of the tube. Totally the most disgusting secretions I've ever seen. Not pseudomonas green, just icky infection green. We suctioned and we suctioned and we suctioned and we suctioned and we suctioned some more. And then SUDDENLY his sats shot up to 100%. At one point during the suctioning I said "Why am I doing this? I only came up here for a soda." The residents both laughed and gave me shit aobut being in the wrong place at the wrong time if I wanted to be lazy and not have to work.
The guy had been so loaded down with secretions he didn't even sound rhonchous. It was like the never ending horror house of slime in this guy. Girl RT suctioned every little bit for several hours to get this guy cleaned out. But once he was cleaned out and she switched over to Bi-vent (Servo vent) then she was able to wean him down to 30%. Rock on! Beats the shit out of 100%, doesn't it?
It was bad but here's the deal. I love it when it all comes together in a very good way so that it's a great intervention for the pt and morale-lifting teamwork for us. I have no doubt that had we not intervened when we did we would have coded that guy on the floor. Instead of a sad turn out the guy should be fine. We got him what he needed when he needed it and he should be fine. I love it when it all comes together so beautifully. It was a win for the patient, the most important, but it was also a win for us and the residents personally to be there hands-on, and a win for our dept showing the residents that they can count on us to take care of their patients.
Today was definitely one of those days when I walked outside to the sun coming up and I thought "That was a good night's work. I love my job."