trainwreck approaching.... choo choo

We attend clinicals twice a week, and luckily, I survived our first 2 back in quite some time. So did my patient. Yes, that would be one patient. It was supposed to ease us back into real clinicals again. (Not that OB/Peds/Psych aren't real clinicals, but totally NOT the same as med-surg patients). However, when I got to the floor Tuesday morning, my previously assigned patient had checked out (probably transferred to a higher level cardiac facility d/t an acute MI). So low and behold, the charge nurse was more than happy to assign me my new patient. Beware when they say.. oh she is a good patient (HA). I should have seen the warning signs... heard the upcoming choo choo.. chug a chug a chug a chug. I didn't but it wasn't long before I was hit by it like a mack truck.

Let me first preface this by saying that under no circumstances should this patient have been on the floor... but should have been in the ICU. She was a full code and in acute heart failure. Her BP sucked and was falling. She was in atrial fib paced rhythm (dual lead pacemaker) with episodes of RVR. She continued to get all of her cardiac meds because the physician said that the benefit outweighed the risks. It didn't matter she was vasodilated in every inch of her cachetic body. Her heart required it. She was on a 100% nrb. She couldn't take but one bite of food before becoming breathless. Her veins sucked. She continued to infiltrate IV site after IV site. So much so that her arms were edematous from the infiltrations. She could not tolerate fluids. Her wbc count was 30.5 but not septic yet (blood cultures were negative, however, it would probably not be long). Thus, she had to have an IV to run her antibiotics. Central line attempts were unsuccessful and would send her into runs of vtach. Her blood sugars were consistently below 60; she refused to eat more than one or two bites. She had pneumonia and pulmonary congestion from the heart failure. Her hgb was 9.5; but had already received 4 units of prbc's earlier in her admission. Now she didn't even have an IV site appropriate to run blood. That is the picture of my two days in clinical. yeah, fun... all I can say for myself is that I am very lucky to work as an extern in the ICU at my hospital or I may have freaked completely out. (my instructor told me more than once that she was impressed with how I handled this patient).

On the upside, I did have the rare opportunity to see the cardiologist start a peripheral IV. I am assured by many nurses that this usually does not happen, ever. He is also the one who was talking to the family when we left about her code status. (I can tell you that I prayed and prayed that she did not code on me while I was there). It was a clinical of balancing on the tightrope, hoping that one small reposition didn't vagal her into oblivion. I also learned a lot. I learned that acute hf patients get their cardiac meds even with bp's as low as they can tolerate. Meds can be changed every hour. Orders written and rewritten every 30 minutes. Vegitation means to look for potential clots (not growing potatoes in the heart as I jested to my classmates hehe). Seriously, I knew it had to be something, I just didn't know what it was.

Next week, I take on two patients. Let them be stable. Hell, self-care would be wonderful even. I know that I am ready to jump back on the bandwagon and take on more than 1 patient, but not more than 1 like I had this week.. our supposed "ease back into the swing of things" week. I think that my clinical instructor would also like the same. Nah, no thinking.. I am sure she is hoping for the same!