The 3rd of Every Month

The 3rd of every month has come again and this day is quickly becoming my least favorite to work.What is the significance of the 3rd you may ask? This is the day when all the new residents start in my unit. Usually the only clinical experience the residents have thus far is working on the floors, not actual ICU experience. Every new nurse is warned of this day during orientation. Because, it is a day when you have to be extra careful and completely on your game. Every order that comes through must be triple checked and questioned and it is best to be in the patients room if the resident enters for any reason. These precautions may seem a bit much, but they are completely necessary. As we say in the South, "bless their hearts." "Bless their hearts" because even though the residents mean well, they really have no clue what is going on at this point.

An example of why nurses should always be extra cautious when working with new residents is an experience I had last night at work. I was caring for a 7 day old coarctation of the aorta repair. The patient's post-op course had been uncomplicated at this point. The patient was extubated earlier that morning, but it was noted that he was having some mild subcostal retractions. When I entered the patients room to complete my full assessment, the patient was severely retracting, using accessory muscles to breath, nasal flaring, etc. I immediately notified the resident. He said just to increase his oxygen. When some time had passed and the patient was still working very hard to breathe, I again notified the resident. He ordered a stat chest x-ray and an ABG. The patient's ABG revealed respiratory acidosis and the resident said out loud to me, the nurse, "Hmmm, this is a tricky one." It took everything in me to keep my patience and this is only the beginning of the story. We started the patient on Vapotherm and the resident did not think we needed to obtain another ABG. He said he wanted to simply manage the patient clinically. I looked at the resident and said "clinically the patient looks like crap."

Throughout the night the patient was transitioned to Nasal CPAP and then back to Vapotherm. Multiple times I had to go over his head and talk directly to the Attending to get anything done for my patient. Later I asked the resident if we were going to move to the next step because the patient was not clinically better. He said that he thought we should leave the patient alone and let day shift decide what they wanted to do with their patient. I had to walk away from the resident. He asked if I was okay with this and I turned around and said that I "absolutely was not okay with not doing anything for my patient." I explained to him that we have tried different interventions that are not improving the status of the patient and that he will only compensate for so long and that I wasn't in the mood to have to emergently intubate the patient during shift change. Now I know that was quite blunt, but it actually got the resident's attention. I was the only one advocating for this patient. I am at the patients bedside all night long and I may not know what is wrong but I sure know when something is not right or normal with my patient. It is that gut instinct that tells you that something has to be done. The patient was stable when I left this morning but had quite the eventful day.

The patient had a repeat echocardiogram that revealed mitral valve stenosis, mitral valve regurgitation and severe pulmonary hypertension. The patient is still on Vapotherm and is breathing more comfortably but is still having mild retractions. They believe that the patients coarc masked all the signs and symptoms of the stenosis, regurgitation and pulmonary hypertension. Usually to treat pulmonary hypertension, we give our patients sildenafil or Viagra. Well, apparently sildenafil can mess with stenosis and regurgitation and vice versa, the medications used to treat the stenosis and regurgitation can mess with the pulmonary hypertension. So the team is weighing the pros and cons of repairing the mitral valve and is supposed to form a plan tomorrow. I of all people understand how scary it is to start working in an ICU and feel stupid all the time, but the problem lies when people put off intervening for the patient because they don't know what to do. I will be very interested to find out the outcome of the patient.

Comments

[Dennis Pyritz, RN]

Nice post! I remember how scary those "baby" doctors can be.

[Sharon O'Kelley RN]

I also remember many a night or day I had to raise up a snot-nosed intern in the Adult medical oncology unit. Most of the time, you are the only advocate for the patient and have to claw your way to provide the proper course of treatment for them.

[Debby Hamolsky]

And were we not new and learning ever? The question is what are the safety mechanisms in each of our systems to address the checks and balances required in our teaching institutions. There is a reporting stucture if one believes aand/or knows that the patient's clinical situation is not being addressed. Our care in hospitals is collaborative - exploring better how to make that work is a fundamental core purpose of collaborative care. Its also been my experience that if we recognize how much our experience has taught us aand teach we will be less intimidating to the young people struggling to become independant physicians - while keeping our pts safe.