Saturday, September 11, 2010

At Least I Know What Unit I Don't Want To Work On

I stood in the hallway outside the room, nervously looking on at my first CRT (Critical Response Team) incident. Before the CRT was called, the woman was on a bedside commode, slumped over and moaning softly. “Clara,” her nurse, shook her shoulder and put the woman’s head between her hands, trying to get her to open her eyes. “Mrs. Jones, open your eyes! Can you hear me, Mrs. Jones? Try to look at me.” The woman was virtually unresponsive. The nurse I was working with ran into the room and asked if Clara needed help. “Call a CRT. Now.” Within minutes, the small room was swarming with help and the woman was whisked off to ICU. The relief Clara felt after the patient was stabilized and off our unit was palpable.

CRTs are sort of a pre-code blue; they are called by the nurse in the hopes that help will arrive and the patient will be stabilized before they lose consciousness and stop breathing. They are not called frequently, particularly on the unit where I work, so it was several months into my training before I experienced the one above. The charge nurse will show up quickly, as will all nearby nurses on the floor, and the ICU charge nurse and another ICU nurse will come down to assist as “another pair of eyes” to help assess the situation. The room fills almost instantly with helpful (and sometimes just curiously nosy) bodies.

Since ending my orientation on the unit and beginning to work on my own, I had a list of three (albeit irrational and somewhat ridiculous) fears that I had successfully avoided dealing with on my own. A month or so ago, I conquered all three of them in a single 3-day workweek, from 3rd most feared to the number one most feared, strangely enough. #3: Changing a PICC-line dressing on my own. (For those other nurses out there, I know this is bizarre. But I’m always afraid they’ll slip out!) #2: Putting a Foley catheter in. (I somehow managed to not put one in since nursing school.) #1: Transfusing blood/blood products. (Legitimate to fear, but still not worthy of months of avoidance.) In any case, I thought I had conquered the worst if it and have been feeling, for the most part, pretty competent at work. The last lurking fear I had that occasionally stressed me out was walking into a patient’s room and finding them unresponsive (or worse) and having to call a CRT or code.

The other day I squelched that one and made it through my first CRT. The man was a diabetic in renal failure who had been evading his nephrologist for some time who wanted to start him on dialysis. He came in for an unrelated surgery and when his labs came back the morning after, a slew of doctors convinced him to stay in the hospital and have a dialysis catheter (Permcath) placed and hemodialysis started. For this surgery, he needed to be NPO (nothing to eat or drink) for at least 8 hours, which can be tricky for a diabetic. Toward the end of my 12 hour shift, I was in the room with him and noticed a slight alteration in his mental status and also that he was profusely sweating. My suspicions proved correct when I checked his blood sugar and it was 30. This is quite low, and can be very serious – the normal accepted low is at least 70, but normal blood sugar is closer to 100. I began to follow our hospital’s protocol for hypoglycemia but despite two attempts, we couldn’t get his blood sugar higher than 60, which is still too low. I notified the MD and implemented the orders. He was started on what is essentially a sugar-water IV drip and I thought everything would turn out alright.

An hour later, I was in the room with him explaining his surgical consent, and within minutes before my eyes he began to decline; he was sweating worse than before and was extremely drowsy, mumbling, and tremulous. I checked his blood sugar immediately and was shaking as I waited for the results, knowing they would be awful. His sugar was 26. I ran into the hall calling for help and snagged a bottle of D50 (very concentrated sugar water) and told someone to call a CRT. In under a minute I had half a dozen nurses in the room assisting me, and within 2 minutes the full critical response team had arrived. My hands were shaking so badly I couldn’t draw up the D50, but someone graciously took over that task. The patient eventually stabilized and after a maddening amount of arguing with the internist, we transferred the patient off the unit.

I will still have lingering worries about worst-case scenarios and crashing patients, but at least I feel like I’ve had a little taste of the worst things this unit has to offer. One this is for sure – with those embarrassingly shaky hands, I sure as hell know the ICU isn’t for me!