What does a Nurse need to learn?

What does a Nurse need to learn by Justine zoeller
 

I push the button to silence the mechanical ventilator for two minutes. The loud "circuit disconnect" alarm makes parents and patients edgy. Besides, an unanswered ventilator alarm is a signal to other nurses - "I need help in here!"- and I know all the other nurses are busy with their patients. I don't want them to have to leave their rooms to check on me. Before suctioning, I usually push another button to give my patient 100% oxygen, but I don't for this baby. With his anatomy, too much oxygen can flood his lungs, decrease his blood pressures, and even cause myocardial ischemia- a heart attack. 

I turn my attention to the squirming infant in the bed. He is silently crying- face purple and screwed up, tears forming in the corner of his eyes. A quick glance at the monitor tells me that his heart rate and blood pressure are high. Not surprising, based on how upset he is at the moment. I disconnect the ventilator tubing from the endotracheal tube. This pencil sized tube is inserted through his mouth into his trachea so the mechanical ventilator can give breaths directly into his lungs. The external portion is secured to his face with tape. It's secure for now, but I'll keep a close eye on it throughout my shift- this is a drooly baby, and the difference of a centimeter in or out can have serious negative consequences. Across the crib from me, the baby's mom winces. "It's so hard to see him like this." "I know," I reply. "The good thing is, he won't remember any of it. You will though!" I try to strike a calm, upbeat and sympathetic tone. She smiles, reassured, but doesn't take her eyes off the baby. 

Carefully keeping my right hand sterile, I advance the suction catheter through the tube into his lungs. I anchor the tube with my other, un-sterile hand as I apply suction and withdraw the catheter. I can tell from the sound that I'm clearing a lot of secretions. "I think it was just the coughing making him upset. If he doesn't settle after I change his diaper, we'll definitely give him some extra pain medicine." She nods. It's good to have a plan. 

On the monitor, I see the baby's heart rate start to dip- 160, 120, 90, 70, 60. Using my unsterile hand, I connect the ambu bag to the endotracheal tube and quickly push breaths into his tiny lungs. His heart rate recovers right away, and his blood pressure was stable the whole time. I think it was just a sinus bradycardia- normal baby business in response to suctioning- but I'll take a closer look at the telemetry later. 

As I pass the suction catheter again, I hear a beeper go off outside the room. My charge nurse sticks her head in. "I'm going to an RRT on 5." RRT stands for rapid response team Any doctor or nurse can call an RRT for a patient outside of the ICU if they're concerned that the patient is quickly getting worse, and a critical care nurse and respiratory therapist will respond. We can perform assessments and interventions and offer recommendations. If we think the patient might need ICU care, or want a critical care doctor's input, we call the covering Pediatric ICU fellow. 

"Okay!" I reply, as I give the baby a few more breaths, satisfied I've cleared the majority of his secretions, and then reconnect to the ventilator. "Who do you have again?"

"I have bed 6. She should be fine, but can you keep an ear out for Christine? Her post-op is starting to get a little hypotensive. We have epinephrine in line and there's blood in the fridge if they want to give volume."

"Sure, no problem. Call me if you need a hand down there."

My vent beeps. Two minutes have passed. 

The baby is already starting to settle. His heart rate and blood pressure have normalized, his eyes are closed and face is calm, and he's sucking on his tube like it's a pacifier. I wash my hands, and make sure mom doesn't need anything right now. I do a quick scan of my room- alarms are on, emergency equipment is available, tubes and IV lines are secure, and I have enough of my continuous IV medication drips to last for a few hours. I go to check on Christine. It's her first unstable post op, and she's probably a little nervous. 

After 4 years in the pediatric cardiac ICU, these actions and conversations and thousands of quick decisions are second nature for me, but I remember a time when they were not. There is so much to learn, and it is all so important. These patients are small and sick. For nurses new to our unit, the things that have to be learned before they are independent clinicians are understandably daunting. 

First- the sheer volume of information. Nursing school doesn't prepare us for the complexity of critical care, or inherent degree of specialization of a unit like this. There are hundreds of diagnoses and accompanying medications and surgeries. There are EKGs, blood gasses, and x- rays. There's specialized ICU equipment- ventilators and monitors, but also pacemakers, and ventricular assist devices, and continuous dialysis, and even long term heart-lung bypass, or extracorporeal membrane oxygenation. I often remind new nurses coming off orientation how much they've already learned. What used to be alphabet soup- HLHS, TAPVR, SVT, RVOT, ECMO, EAT- has become a common language, a tool for sharing information about our patients. 

The psychomotor skills. Nursing is hands on. We touch to feel pulses, skin temperature, swelling, induration. We bathe, we suction, we secure, we insert, we remove, we change dressings, we change sheets. We do these things carefully- sometimes steriley- to prevent further harm or infection. New skills are slow and clumsy, and take time to become as quick and sure as they need to be. 

The culture. Some things are simple. Safety first. We answer each other's alarms. We help each other. We treat parents with kindness and respect, even if they're difficult, because they're always having a worse day than us. If there's a code, we drop what we're doing and go help. Some questions are less clear. What tasks are okay to leave for the next nurse? How do you handle a patient or family member who doesn't treat you with respect? If the patient needs more pain medication, or their blood pressure is low, or their most recent blood gas shows an increasing acidosis, who do we talk to? More difficult still- what do we do if we talk to a provider and disagree with their plan? How hard do we push? How quickly should we escalate?

New nurses have to synthesize all of his new knowledge and experience to make decisions in real time. Some decisions aren't time sensitive and can be debated- should I turn the baby to the other side or let them sleep? Is this endotracheal tube tape secure enough or should I re-tape it? Many decisions are more critical and cannot wait. Should I call the doctor about this low blood pressure, or do I need to do something right now? Will this heart rate come back up when I give a few breaths with an ambu bag- or do I need to start chest compressions?

Then, slowly, surely, they put it all together. They assess and intervene and make quick decisions and perform necessary skills confidently and correctly while calming anxious parents. While calling the doctor and the blood bank and the lab. When, unpredictability, things change. A very sick kid at a different hospital needs to come right now. A post-op won't stop bleeding, and his chest needs to be opened emergently at the bedside. They do it when there are not enough nurses, and there's hardly time to think before rushing off to the next task. These new nurses handle it, and with each new experience their skill and competence grows. They have learned so much, and they are not the same. 

They go home, and they wonder if they did enough, and their families ask how work was. "Fine." They say. “Busy, but fine.”