Monday, April 11, 2011

Stepping Back, Major Arteries, and X yo’s

Stepping Back

So, I’m 9 months into working as an Acute Care Nurse Practitioner at Duke Raleigh Hospital. Like with any job, there are good days and bad days, good experiences and bad experiences. Overall, I’m very blessed that I have Attending Doctors who care about me and my professional growth and make an effort to make me better. For this I am extremely grateful.

Part of the reason I took this job was to become efficient at procedures. Procedures are skills that I can perform as a Nurse Practitioner that I can’t perform as a Registered Nurse; skills including intubation, central line placement, arterial line placement, suturing, chest tube insertion, etc. Most of it is blood and guts type of stuff, fun stuff.

So, in order to be credentialed, or checked off, I have to be observed performing each of these skills ~10 times. Some skills are rather easy to dominate and others take much more effort. Fortunately I have great Attending’s who have invested a lot of time in making me proficient. Actually, too much.

It was my 10th time, my finally observation. And there He stood. He is my boss, my primary Attending.

Now, you have to understand that when performing these skills I must be sterile. There is a big difference between being sterile and being clean. Being clean means you aren’t dirty. Being sterile means you have no “bugs” on you. So, in order to be sterile, I have to gown and glove up (note picture). This means that my body is completely enshrouded by some type of sterile material, this means I’m hot and sweating.

When one is slightly bent over a patient, breathing down their neck (through a mask of course), for the purpose of placing a central venous intrajugular catheter, while sweat is dripping down your back and between your…, the last thing you need is someone breathing down your own neck. Yet, there He was. As, I said, this was my 10th time. By this time, I know what I’m doing; yet, there He, in my face, breathing down my neck (through his mask of course).

In truth I’m ignoring him, we have an excellent professional relationship and as he’s blabbing I’m listening to my own thoughts, going through the steps in my own mind, disregarding his words. Then he attempted to intervene, attempts to redirect and reorder my steps.

I realize this is the moment, my moment to take control. If I don’t take control I’ll never stop being observed and He will always be there.

So as he is talking I look up and look him square in the eye. He stops talking. “Yes” he asks.

“I need you to step back!” I say. Yes, I said this to my Attending, to my boss.

Fortunately, he smiled, ho bowed his head, he nodded obligatory, and he stepped back. That isn’t to say that he was silently through the remainder of the procedure, but that was my last observation. So, I’m not sure if we so much as have an excellent professional relationship or if I’m just really lucky.

Major Arteries

Since I was “checked off” on central venous intrajugular catheter placement, I’m now allowed to place this line by myself, unattended, without the presence of a Medical Doctor.

Now the thing with procedures it that there are risks involved, that’s why you have to have advanced training to perform them, that’s why you have to be credentialed, that’s why you have to be “checked off”. Fortunately none of those things have happened to me, after all, the chances are small. These things include causing an embolus (or a traveling blood clot), cutting a major artery, infection, losing a wire, and death, just to name a few.

A few shifts after being credentialed I was past ready to put a line in (a central venous intrajugular catheter ) unattended. Now when one places a central venous intrajugular catheter a lot of large needles, scalpels, and other sharp objects are used to shove a large IV into someone’s neck.

The opportunity came.

It was a Saturday night, I’d slept all day and I walked on shift ready to work. I made my normal rounds, did a foot of the bed assessment on all my patients and was ready for the night to start. Then it happened. A patient, who wasn’t mine, started to crump (this means bad things were happening to the individual). They needed me to come in and put in a line. In fact, the patient’s doctor stepped out of the room and asked me to come in and put in the line.

I was needed. I was so excited. I was so nervous.

I acted cool. I got my stuff together, gowned and gloved up, stepped in the room, and within moments had the line in, placed some of my most beautiful stitches to date. Just to top it off I added an arterial line for good measure. I was the stuff, I was unstoppable.

I left the unit, went to my office, closed the door, and silently hooped and hollered, did a little dance and simply patted myself on the back. I was the stuff.

The night was young and I was on fire.

Hours passed. It was 0200, now Sunday, and a different patient across the unit was crumping (remember, bad things are happening). I called my Attending, who was at home in his bed, and after a brief discussion, we decided I would put a line in. After all, I’ve been “checked off”.

So, once again I gather my stuff, gown and glove up, and head into the room, ready to place my line. Ironically, I’m in the same room as I was before with my Attending in which I told him to “step back”. Could life be any better or what???

The patient was a bleeder, this means they have thin blood, the littlest prick results in profuse bleeding. This means I’m going to make a mess. Ok.

I get right to work. I see the vein on ultrasound, make my mark, prep and I’m in. Easy breezy. But I’m having a little trouble, my dilator isn’t quite going in like I want. So I get my scalpel to make my incision a little big bigger. That’s when it happened. I cut my patient’s major artery. I cut the jugular. I cut the jugular artery. I cut the jugular artery. Did I mention the patient was a bleeder?? Blood was spraying everywhere. I cut the jugular artery!

To make matters worse, the patient is waking up. Profanities are flying from the patient’s mouth, which are actually quite hilarious. I had admitted this patient. They knew me. They knew me well. They were threatening to slap me when it was over. Did I mention I cut the jugular artery? Blood is everywhere. So I start to hold pressure. I know that I’m going to have to hold pressure for quite a long time and no one else can help me because I’m the only one who’s sterile. So the next thing I know, a chorus of registered nurses have gathered outside of the patients room and they are all standing there watching the scene. Are they rushing in to help? Are they quickly gowning and gloving up to assist me? No. They’re laughing. The chorus of nurses are standing outside the room laughing.

The bleeding finally stopped. The line was successfully placed in the other side of the patient’s neck. I wasn’t slapped. The patient improved. And in the end, I’d had an experience unlike any I’d had before. I’d been afraid of cutting the artery as I’d never seen it happen before and knew that it was only a matter of time. Now I had. And while messy, I wasn’t so scared anymore. Hopefully, thought, I won’t cut it again.

X yo

I admitted the patient through the ED around 0400 in the morning. They couldn't breath. Good air wasn't getting in, bad air wasn't getting out. They were hypoxic. They were breathing 60x a minute. The heart rate was in the 160's. Just sick.

I told the patient they needed to be intubated. They didn't want it, shook their head. I found out later they were a paramedic. They knew what I was going to do to them, they'd seen it. Sometimes I hate when patients understand. We talked again. I talked with the ED doc. We tubed the patient. We intubated.

After we tubed the patient, they kept looking at me, grabbing my hand and saying around the tube "I can't breathe". We started sedation. Tubing a patient is very uncomfortable. "Just relax" I said.

We brought them up to the ICU. The parents, they were so sweet, so grateful, so understanding, so humble. We needed to get them stable, ship the pateint out to the big house. They were sick.

The patient remained incredibly agitated. They continued to reach for my hand and mouth the words "I can't breath". Huge amounts of sedation wasn't even touching it.

My shift ended at 0730. I dictated my note. I was leaving to go home, go to bed; I would be back in less than 12 hours. I was heading out the door and something tugged at me.

I went back and looked that father straight in the eye. I shook his hand and said words of insignificance to him, "I wish you well", "I'll be praying for you", "Good Luck", "blah, blah, blah". He looked right back at me, "thank you for all you did", "you've been so helpful".....

I went to bed.

I returned at 1900.

"You know that kid, that X yo you admitted".


"Yeah, sad thing, they died at 1530".


People die every week. I have the "death talk" with families all the time ("We've done all we can do....."). Normally, it's no big deal. It rolls off my back and I go on. That's what we do. That's what I do. But this. This one got me.

What could I have done different? More fluid? I should have given more fluid. Maybe I should have put a line in? I had time, I should have put in a line. Increased the PEEP. I should have gone up on the PEEP. Question after agonizing question.

The truth is, nothing would have changed the outcome. Maybe prolonged it, but not chagned it.

I thought about this case for weeks. Then I thought about that Father. I wonder what agonizing questions he's asked himself.

I wish.

I don't know what I wish.

Sometimes things just happen.