Working in a Level 1 Trauma ICU is fast-paced to say the least. There isn’t much that happens on the unit that is in slo-mo. The staff takes this for granted sometimes. We are so used to the ‘pulse’ of the floor that what most would consider an emergency that warranted calling a ‘code’ and/or ‘condition’ we take as the typical day at work. This becomes apparent more so when we have GN’s and new employee’s on orientation. What has become a reflexive response for us, is new territory for them. And the only way for them to become ‘reflexive’ is to throw them in the pool and help keep them afloat.

The other day a ventilated pt’s heart rate went from the 80’s to the 220’s in a blink of an eye.

Of course we did what we always do. You follow your ACLS guidelines and protocols. You get a hold of the physician on the floor. We hooked the pt up to the defibrillator with defib pads attached.

In a matter of seconds we’re following protocols and taking orders from the Doc.

Adenosine 12mg IV push… Lopressor 5 IV push X 2… Recheck rhythm.. Reassess pt.. Draw up some Versed 4mg IV… Amiodarone 150mg IV push… Reassess..

During all of this.. we have 3-4 GN’s watching nervously… watching intently… taking notes… whispering amongst themselves.. while we’re doing our job.

It dawned on one of us. HEY.. How about we get the GN’s involved??!!

DUH!?

This was a golden opportunity for the newer, less experienced nurses to get a real taste of what a ‘code’ is like. It was what we refer to as a ‘controlled code’. It had all the makings of a pt in distress, without the involvement of the flow of bodily fluids, rapid infusers, and surgical instruments. So this was the perfect learning environment. And to add icing to the cake we had over a handful of senior staff at their side.

Every nurse out there remembers that "Fear of Death" feeling you had in the pit of your stomach at your first code. I think it’s the only place a human being can feel excitement, fear, anxiety, nervous, curios, and down right awe all at once.

The only thing that can help a new nurse get through that first time is to help ‘control’ the environment with encouragement, guidance, positive reinforcement, and patience. And in this situation we had all that and more!

The ‘code’ was packed full of learning experiences. It had SVT, Sinus pauses, hypotension treated with vasopressers. We then had to reintubate the patient because in the thrill of the situation the patient bit the pilot tubing of his endotracheal tube. So with no cuff pressure they were getting no positive air volume. Re-intubation came with paralytics and sedatives, pulse ox monitoring, and some good ole’ Bag-valve mask oxygenation.

As you can see we had the works.

It was a successful ‘code’. The patient recovered with no residual injuries. The GN’s got their feet wet, and we not only helped a patient in distress but planted a couple seeds of growth in our awesome nursing profession.

We reap what we sow.

Carpe Diem

So in lieu of my last post on Wallpaper, I thought I’d throw another log on the fire and continue talking about noises and/or alarms on the nursing floor.

The other day I was tending to one of my patients. A fellow co-worker walked by and asked if I need any help, and I kindly declined. (At that time I was ACTUALLY caught up with all my work)

My co-worker disappears only to return shortly asking me if ‘that noise’ coming from your other patients room is ‘normal’.

Side note : The word ‘normal’ is a term used very, very loosely amongst fellow nurses. You’d be surprised what we consider to be normal.

So I of course saunter on over to my other patients room to listen in on the curious ‘noise’.

Background : This particular patient was a trauma pt who had multiple respiratory challenges during his stay. Everything from getting a tracheostomy tube, multiple chest tubes (with one still in place, multiple separate bronchoscopy’s, as well as battling pneumonia. On this particular day he was recovering nicely. He was on a 50% Aerosol Tracheostomy Mask. He had been producing excessive amounts of secretions from his trach site, so his coughing was ‘normal’. He also had a slight case of tracheitis. To add insult to injury the mental state and compliance of the patient was also a challenge. He required high doses of sedative medication to keep the patient safe from self harm.

I enter the room to the sound of seals barking.

Every time my patient coughs there is this audible ‘barking’ noise?

Now throughout my shift this patient would produce a croup-like sound when the patient had a hard coughing jag, but nothing like this sound.

So (for all my student nurses and new grad nurses) here’s where those ‘critical thinking skills’ come into play.

The patient is now in increasing respiratory distress. You have the audible sound that shouldn’t belong. And now his oxygen saturation is starting to decline. All other trouble shooting checks have been made, and have been cleared. (trach cuff is inflated, pt is getting same amount of oxygen as before, no new bodily fluids or blood present, vital signs, etc, etc)

THINK…

THINK…

THINK…

Uhh.. he still has a chest tube. How about we check that?

Glory BE!

The patient, during the horrendous coughing jag, somehow managed to yank at their chest tube while batting their hands on the bed so hard that their chest tube was dangling at the skin.

Enter – TORNADO EFFECT

In one fail swoop, the Trauma Docs are called. And yes the chest tube was out.

We go through the gamut –>

- Doc pulls out chest tube that’s hanging on by a thread

- Doc gets gowned up for new chest tube insertion

- Pt has sucking chest wound while sterilizing site

-New chest tube inserted

Now from the time I stepped into the ‘seal barking’ noise to the new chest tube insertion… I think a total of 10 minutes might have lapsed. And the longest portion of the whole scenario was the sterilization and gowning up to place the chest tube. (The patient had already spiked another fever, so we needed to keep things as sterile as possible)

So the lesson learned….?

Not all noises are Wallpaper.

Carpe Diem

The alarms on your monitors.

The call bell lights flashing.

The call bell alarm being triggered.

The unit phone ringing.

All of them can be, and are often subliminally categorized as Wallpaper.

It was a term coined by a fellow nurse who was the Safety Officer for a certain hospital I used to work for. During the general hospital orientation, he gave the wonderful speeches on sentinel events and reporting procedures for those events, if they were to ever happen.

He went on to explain that we as nurses will get used to the alarm ‘noises’ we are so often subjected to, that they no longer become an alarm or an alert. We (by no fault of our own) no longer consider them to be ‘something out of the norm’, nor do we change our direction or way of thinking when these cues are readily apparent to everyone else surrounding you.

We become so oblivious to the ‘alarm’ that some may think we are ignoring the said alarm.

Take for instance the patient call bell. A noise every nurse hears during those silent sleeping hours lying in bed after a long shift at work. A noise that given the opportunity or chance, every nurse could mimic down to the specific chord and/or note.

Unfortunately, during our work day it becomes wallpaper. It turns into an accepted sound that we subconsciously consider to be the ‘norm’. We don’t purposely ignore the alarm, but when you hear the alarm repeatedly all day, it stops becoming an alarm and start becoming that background noise, ergo wallpaper.

The irony of it all, is these alarms are supposed to alert personnel that something has veered from the ‘norm’.

So now, the patient has pushed the call bell and you’re not acknowledging there need. The patient and the patient’s family knows what the use of the call bell is for, and they also know YOU as the nurse know what it is for. Therefore, since you are not answering the call bell alarm, you MUST be ignoring the needs of the patient.

We are so often quick to judge.

Sometimes the craziness of the work environment causes adapting and changes in our psyche that elude our normal way of thinking and our normal way of acting.

The next time a nurse isn’t answering your call bell please be a patient patient and think about what workplace wallpaper you have.

Have you ever accidentally answered your home phone with the phone greeting you use at the office? And not even realize you’ve done it?"Hi, thank you for calling (so-and-so). My name is (so-and-so). How can I help you?"

It really is amazing what you get used to-

Carpe Diem

There has been some discussion lately about a nurse’s job choice and job difficulties. Do you stay or do you go? What sways you to choose one facility over another? Do you stay in your comfort zone, or do you remove the security blanket?

I’d like to focus on the job environment itself. It’s a place we all love to hate, and hate to love. It has many great joys… and an equal amount of (headaches) difficulties.

There are staples of the job environment that you are going to find no matter where you work. No matter what type of environment. Yes the intensity of these mainstays may change, and they may even have different names or different faces. But trust me, they are in every work environment you will ever experience.

• Their will always be a group of people, or a singular person who loves where they work (Tigger)
• Conversely their will be a group of people, or a singular person who hates where they work (Eeyore)
• The ‘air’ on the floor will be determined by whether or not the Tigger’s out-number the Eeyore’s
• Your manager does not have a direct effect on the flow of floor. They do manage and are directly responsible for all that goes on, but they aren’t in the trenches most days
• Just because you get along well with the manager does not reflect how well it will go on the floor
• Everyone is short staffed. It’s a fact of the nation. Get over it. Get used to it.
• We all would love to be paid more. Who wouldn’t
• Team work is not something forced or expected, but something given and earned
• Respect is not something forced or expected , but something given and earned.
• Scheduling is rarely fair, until you speak up.

And here are three questions you should always ask yourself when interviewing for a position on the floor

• Look at the faces of the staff when they enter through a door (ANY door). Are they smiling? Are they grumbling under their breath? Are they giving the 1000 yard stare?
• What is the staffing mix? Is there a fairly equal mix of new and experienced nurses? This is a key element if your a new graduate nurse. Have the staff forgot what it’s like to be a new graduate?
• What is the staff’s opinion of the physicians in regards to treatment of nurses? Most floors have a resounding yes or resounding no. Mixed answers are as bad as the resounding no.

In my humble opinion these facts and questions can and will help you determine your place in this wonderful career we call nursing. Choosing a job for most other reasons doesn’t guarantee the shade of green, just the other side of the fence.

Carpe Diem