Starting Out: A New RN In the MICU 5/1/04

1- What kinds of patients come into the MICU?

2- How do families interact with the MICU staff?
3- Who are the nursing staff in the MICU?
3-1- Who are the resource nurses?
3-2- Who is the nurse manager of the MICU?
3-3- Who is the Clinical urse !pecialist?
3-"- How are the assignments made?
3-#- Who are the CC$s?
3-%- Who are the &'s?
3-(- Who are the U!'s?
"- Who are the doctors in the MICU?
"-1- How are the ph)sican teams organi*ed?
#- What does +espirator) $herap) do in the MICU?
%- Who are the other staff in the unit?
(- What are the routines that we use in the MICU?
(-1- How do I manage m) time during m) shift?
(-2- How do I use the flow sheet to organi*e m) time?
(-3- How should I gi,e report?
-- What do I need to know a.out the monitors?
--1- !hould I .elie,e e,er)thing the monitors tell me?
--2- What can the monitor do?
--3- How does the information get from the patient into the monitor?
--"- How should I react to the alarms?
/- What are the different pumps used for in the unit?
/-1- What are microinfusion pumps?
10- What are all the lines going into these patients?
10-1- How does the line connect the patient to the monitor?
10-2- What are the inflated white .ags for1 that hang on the poles in the rooms?
10-3- Wh) do the) use that stiff tu.ing for the transducers?
10-"- What should I worr) a.out when using these lines?
10-#- How should I organi*e the lines?
11- What kinds of la.s do we send on the ICU patients?
11-1- What do I do with the results?
1
12- What is the procedure for admitting a patient to the ICU?
12-1- 'dmitting from the &+?
12-2- What are 2.oarders3?
13- What do I need to know a.out gi,ing meds in the ICU?
13-1- What are pressors?
13-2- What other drips do we use?
13-3- How do I make sure that I4m doing all this correctl)?
1"- What are some of the tests that the patients ma) ha,e done here in the
unit itself?
1#- What tests do patients tra,el out of the unit for?
1#-1- How do I take a patient to C$ scan?
1#-2- What do I do when I4m at the scanner?
1#-3- What other scans do patients tra,el for?
1%- What do I need to know a.out I5 access?
1%-1- 6eripherals7
1%-1-1- Where should the) go?
1%-2- Central lines7
1%-2-2- Where should the) go?
1%-3- !hould I put in m) own peripheral lines?
1%-"- What do ICU nurses gi,e through I5s in the unit?
1%-"-1- Cr)stalloid7
1%-"-2- 8lood products7
1%-#- I5 meds7
1(- What are some of the common emergenc) situations that come up in the MICU?
1(-1- !ome .asic thoughts a.out emergencies7
1(-2- Cardiac9hemod)namic situations7
1(7271- H)potension7
1(7272- 'rrh)thmias
1(-2-3- ot-so-scar) arrh)thmias7
1(-2-"- 2:lashing37 ;o1 not that kind<=
1(-2-#- Codes7
1(-3- +espirator) situations7
1(-"- I> issues7
1(-#- +enal failure7
1(-#-1- Urolog) pro.lems7
1(-%- ?I situations7
1(-%-1- ?I .leeds7
1(-%-2- @i,er failure7
1(-(- eurological situations7
1(-(-1- What should I worr) a.out?
1(-(-2- 8olts7
1(-(-3- ' *e.raA
1(--- 6s)chiatric situations7
1(---1- &,erdoses7
2
1-- How do I deal with m) own stress in the unit?
1--1- 8eing scared7
1--2- :eeling stupid7
1--3- What do I do if I make a mistake?
1--"- What if I find someone else4s mistake?
1--#- What do I do if I think the doctors are telling me to do the wrong thing?
1--%- What if I think the doctors aren4t listening to me?
1--(- How should I go up the chain of command if the doctors aren4t listening to me?
1---- How should I in,ol,e the resource nurse?
1--/- What do I do if I think that the patient treatment is unethical?
1/- ' word a.out le,it)A
$o start withA
In thinking a.out how to organi*e this :'B1 it certainl) seemed that there was a whole lot of
material to co,er C where would )ou start? &.,iousl) from somewhere777 a little later1 I reali*ed
that a good wa) to put things together would .e to descri.e them in the same wa) that we gi,e
shift report C in the same wa) that we tr) to co,er all the .ases when we do that1 starting with
age1 gender1 histor)1 where admitted from1 and then a s)stem-.)-s)stem re,iew of the patient1
ending up hopefull) with a coherent picture of the current situation7 !o I thought that this might .e
a useful wa) to .reak up a description of the ICUD into managea.le chunks that1 while the) could
.e descri.ed separatel)1 should add up to a whole s)stem for treating whate,er comes in the
door7 @et me know what )ou think< 6lease remem.er that this material is in no wa) Eofficial4 C it is
meant to represent information as it would .e passed from a preceptor to a new ICU nurse7 's
usual1 mistakes C and there will .e plent) of them C are mine7 6lease let me know when )ou find
them1 and I4ll work the answers in and update the file7 $hanks<
$o start with C here4s a scenario that I remem.er all too well7 It was a little eFtreme1 .ut it4s a true
stor)1 and it helps illustrate a lot of what makes working in the ICU so differentD ;lots of the details
ha,e .een changed to protect identities=7
' patient comes in as a transfer from another hospital7 He4d .een .rought down from somewhere
in ew Hampshire1 where he4d .een eating home-cured meats and apparentl) drinking home-
made liGuor7 He4d gotten a stomachache1 so he took 2a handful3 of aspirin7 When this didn4t help1
he apparentl) repeated the dose7 6ro.a.l) a .ad idea Che de,eloped an enormous lower ?I
.leed1 .ecame h)potensi,e1 and .) the time he finall) got to us1 he4d infarcted much of his .owel1
knocked off his kidne)s1 gone into shock li,er1 and when I first saw him he was postop1 ha,ing
had a large segment of his .owel remo,ed7 He4d reGuired so much fluid peri-operati,el) that the
surgeons had .een una.le to close him C instead1 his a.dominal wound was open1 co,ered with
a clear1 adherent &+ drape1 and he had normal saline infusing into the wound continuousl) from
se,eral I5 pumps for irrigation7 $he wound was .eing drained .) se,eral salem sumps laid into
and across the incision7 He was in '+>!1 so he was ,ented1 sedated1 and chemicall) paral)*ed7
He was eFtremel) septic1 h)potensi,e1 and he was on at least two pressors7 He was on $67 $o
correct his renal failure he had .een started on C55H ;.edside dial)sis=7 I4ll put each part of the
report that I might gi,e in Guotes1 and I4ll tr) putting the topic .eing discussed into some kind of
dialogueD 2Hol) cow1 this gu) is in tough shape73
3
1- What kinds ! "atients #$e int the ICU%
2$his is Chuck M7 Chuck is a 3--)ear-old gentleman who came in )esterda) from an outside
hospital1 where he ingested too much aspirin after apparentl) eating and drinking home-cured
meat and whiske)A3
6atients come into the MICU from a ,ariet) of placesD the floors1 the H+1 as transfers from other
hospitals1 as postops1 as .oarders from other ser,ices1 and sometimes as 2direct admits31
.)passing the H+7 $he interesting thing a.out the MICU is that we literall) see a .it of a.solutel)
e,er)thing1 unlike the specialt) ICUs7 If )ou work here long enough1 )ou4ll see patients that would
normall) .e in e,er) other ICU en,ironment ;eFcept ma).e fresh postop cardiothoracic patients C
that ICU will .ump more sta.le patients out to make room=7 We see cardiac patients1 sometimes
with intra-aortic .alloon pumpsI we see neuro patients1 occasionall) with monitored .olts in place1
we4,e done adult HCM& a few times1 and we e,en sometimes get general-surg postop cases
when there is no room in the !ICU7

&- 'w d !a$i(ies intera#t with the ICU%
2Chuck has a girlfriend here who4s .een in and out a few times C I4m not sure what the
relationship is1 and I4m not sure who could sign for consent on his procedures1 so would )ou
speak to her and figure that out? $hen ma).e we can help her find a place to sta) near.)7 We
ma) need to do some teaching with her .ecause she gets ,er) upset when she4s .een in the
room for a more than a few minutesA3
$here4s .een a lot of discussion and planning o,er the )ears a.out the wa)s that we can in,ol,e
patients4 families in the MICU7 't this point we ha,e no fiFed ,isiting hours1 .ut access to the
patients is strictl) at the discretion of the nurses7 $he emphasis is on allowing access for families
at an) time of da)1 .ut our first responsi.ilit) is the direct care of the patient7 $he famil) ma) .e
ad,ised to remain in the waiting areas until the patient can .e ,isited7 We tr) to keep the num.er
of ,isitors to two at a time1 to pre,ent crowding in the room7 's well1 usuall) we tr) to identif) a
famil) mem.er who will .e willing to act as famil) 2spokesperson3 C all Guestions and answers to
.e rela)ed to other famil) mem.ers through that person1 so that the nurses don4t ha,e to spend a
lot of time eFplaining things to man) sets of ,isitors7 $his goes for phone calls too C )ou can refer
callers to the spokesperson7
)- Wh are the nursing sta!! in the ICU%
2I took report from !usie7 Jou know1 I am so totall) intimidated .) her1 .ecause she4s .een here
so long? I mean1 she4s reall) nice1 .ut I don4t know1 I Kust feel so stupid around herA3
$he MICU nurses ha,e a wide range of eFperience1 ranging an)where from three months to
upwards of twent) )ears7 ;Jou can tell who those are right awa)7= I4,e .een working in this unit
since 1/-%1 and I reali*ed around m) last .irthda) that I4,e spent a third of m) whole life working
with some of these people7 We ha,e nurses with diplomas ;I4m one of them=1 .ut most of us ha,e
finished 8!s7 !ome of us are1 or ha,e .een CC+s1 and some of us ha,e special areas of
eFpertise C C55H1 or .alloon pumping1 or leadership1 or skin care1 or I5 insertion C learn who
these people are and make use of them<

)-1- Wh are the resur#e nurses%
!hift-to-shift leadership is pro,ided .) the resource nurses1 who carr) no patients1 for the ,er)
good reason that the whole ICU is their assignment77 $he) make out staff assignments1 and
arrange for admissions and discharges with the super,isors and the house officers7 $he) are also
there to .e )our 2resource3 for an) situation or Guestion )ou ma) ha,e7 Use this resource an)
4
time )ou think )ou need to7 A(wa*s run an) Guestion )ou ma) ha,e .) )our resource nurse7 't
the same time1 tr) to .e merciful1 and remem.er that the) are keeping a lot of .alls in the air at
once<
)-&- Wh is the nurse $anager ! the MICU%
&ur nurse manager is a master4s prepared +1 with man) )ears of eFperience in a ,ariet) of
leadership settings7 !he had alread) .een a head nurse in our hospital1 some )ears .ack1 .efore
.ecoming a nursing super,isor7
'n important point to remem.er a.out our nurse managerD like the rest of us1 she is doing a Ko.
that reGuires keeping a ,er) large num.er of .alls in the air at the same time7 Most of us senior
nurses shake our heads in wonder sometimes1 as we watch the nurse manager field staffing
crises1 unusual clinical situations1 and that most difficult of managerial pro.lems C staff politics7
$he .oss has an eFtremel) compleF Ko.1 and unlike the rest of us1 she is 2on3 2"9 (7 I ha,e .een
impressed o,er the )ears with her consistent willingness to face tough pro.lems and see them
through7
'nother pointD the role of the nurse manager in the MICU is clinicall) 2hands-off37 $he
management model tries to shift most of the clinical management responsi.ilit) issues to the
clinical nurse specialist7 !o it4s .een a while since the .oss wore scru.s7 Jou will find howe,er
that she is ,er) up-to-date in her clinical knowledge1 and that she works ,er) hard to keep it that
wa)7
)-)- Wh is the #(ini#a( nurse s"e#ia(ist%
$he role of the clinical nurse specialist .asicall) centers around clinical staff support7 $his is the
person to go to when )ou ha,e a clinical Guestion1 a Guestion a.out a medical issue1 a.out a
nursing issue1 a.out procedures1 eGuipment1 policies C an)thing that has to do with immediate
.edside care7
&ur clinical nurse specialist Koined us a )ear and a half ago7 !he has a ,er) .road .ackground of
ICU eFperience1 including man) )ears in surgical intensi,e care1 and pre,ious eFperience as a
C! in another hospital7 ;Jou mean there are ;gasp= C 2other3 hospitals?= ' tradition of our
institution is that other hospitals are alwa)s referred to in chart notes as 2&!H3s C 2outside
hospitals3D 2Jeah1 well1 that M+I was done at the outside hospital1 so1 )ou know1 the)4re goIng to
ha,e to do it again here to make the staff happ)73 &rD 2I Kust do not understand what in the world
the) thought the) were doing with this patient at that outside hospital7 I mean1 30 centimeters of
6HH6? :or two da)s? 'nd the) were surprised when the patient started popping pneumos? What
the heckA?3
:or all the complaining that )ou4ll hear us do1 we are ,er) proud of where we work7 We would
ne,er allow oursel,es to .e treated an)where else in the world7 ot in our own ICU howe,er C
and it has come up< We go into the CCUA I guess I can put in an unusual anecdote hereD a )ear
or so ago1 one of our reall) prominent staff ph)sicians flew o,er to Hurope to assess one of the
most powerful people in the world7 He .rought the person .ack C ,er) nice person C on a pri,ate
Ket7 What ICU1 of all the ICUs in the world1 did this patient choose to .e treated in? 'nd )ou know1
we took care of him meticulousl)1 Kust like the street person in the neFt room< We are ,er) good
at what we doA
)-4- 'w are the assign$ents $ade%
'ssignments are made with lots of considerations in mindD we tr) to gi,e primar)9associate
nurses their own patients first1 and we tr) to keep the same nurses assigned to the same patients
e,er) da) if possi.le7 $his ma) ,ar) if1 for eFample1 the patient goes on C55H and their primar)
can4t run it7 We tr) to make reall) acute patients one-to-one1 .ut since this closes a .ed1 we
5
watch these situations closel) to see if things ha,e impro,ed enough to allow for the patient to .e
dou.led later on7 Most assignments are dou.les1 and we tr) to work in all the issuesD
primar)9associate relationships1 acuit)1 distance .etween rooms1 skills of the +s a,aila.le1 etc7
5er) rarel) a nurse will get a triple assignment C usuall) this means that one of the patients is
a.out to .e discharged to the floor7 &nce a )ear1 ma).e1 a patient will .e two-to-oneD this actuall)
happened recentl)1 with a patient who reGuired upwards of 200 ;true stor)<= .lood components
during the course of a da) .efore going to the &+7
)-5- Wh are the CC+s%
We ha,e a num.er of critical care techs in the unit7 ?enerall) these people tend to .e made of
solid gold7 $he) are a,aila.le to help )ou in a num.er of wa)sD .aths9.ed changes1 .lood draws
from '-lines or peripheral sticks ;including .lood cultures=1 room setups for admissions1 line
setups for transduced lines1 fole) insertion1 trach care1 chest tu.e dressings1 HL?s1 2road trips31
and general feats of strength7 $he) check all emergenc) eGuipmentD transport .oFes1 intu.ation
.oFes1 pacer .oFes1 tra,el eGuipment1 M+I kits1 HL? machines1 defi.rillators1 and Molls7
$he) can4t do some things1 and )ou should ne,er ask them toD for eFample to touch1 run or
silence an) of the infusion pumps7 $he) are not allowed to touch I54s1 .ut the) can >C them1 and
the) can >C unsutured '-lines7 $he) are not allowed to tracheall) suction patients7 $he) are
allowed to silence a room alarm onl) if an + tells them to1 and is present in the room7
)-,- Wh are the OAs%
We also ha,e a group of &perational 'ssociates in the unit1 headed up .) an &perational
CoordinatorD these are the people who sit .ehind the front desk7 $he) make the unit runI the) get
us what we needD eGuipment1 paperwork1 .lood productsI the) transcri.e our orders for usI the)
field our Guestions and pro.lems of e,er) descriptionI the) contact personnel all o,er the house
for usI the) speak to patients4 families for us1 and the) follow up to make sure things were done
right7 8e merciful with the &'s C the) also keep man) .alls in the air at once7
)--- Wh are the USAs%
U!'s on the unit are the people who take care of the unit4s ph)sical en,ironment7 !ome of them
ha,e .een in their positions longer than an) nurse in this unit7 $he) ha,e a tough1 detail-oriented
Ko.7 otice sometimes how clean this unit is7
4- Wh are the d#trs in the ICU%
2$he Kunior on tonight is +alph C )ou remem.er him from last )ear? $he red intern is Marcia1 and
the .lue intern is Helmut1 who I think is from ?erman)7 $he fellow was in talking to them a.out an
hour ago1 .ut the)4,e .een lining up another patient1 so I don4t know if the) changed plans on this
man or not7 Howie is the ,isit1 and I think he4s actuall) here1 so we can ask him what the latest
plan isAI reall) hope the) don4t want another M+I73
4-1- 'w are the "h*si#ian tea$s rgani.ed%
&urs is a teaching hospital1 and so the doctors are organi*ed into teams with a senior resident as
the .oss1 Kunior residents under them1 interns at the .ottom1 often with med students attached7
We actuall) ha,e two senior residents leading two teams in the unit at a time1 changing e,er) first
of the month7 $he unit as a whole is super,ised .) a medical director and an assistant director1
.oth pulmonar)9intensi,ist attendings from the in-house group1 who are also called E,isits47 $hese
people take monthl) turns leading rounds1 so )ou4ll hear people sa) 2Who4s the ,isit this month?37
$here are also pulmonar)9critical-care fellows attached to the unit7 $he) are a,aila.le for
Guestions that the team ma) ha,e during the da)1 and the)4re pagea.le for pro.lems at night7
6
:ellows place 6' lines for the team C sometimes the)4ll come in Kust for that purpose during the
night1 and the)4ll help figure out complicated management strategies7
$he two resident teams in the unit are called Ered4 and E.lue4 C .oth teams are present in full force
during the da)1 so the unit gets prett) crowded7 't night1 the teams alternate putting a Kunior in
charge of the whole unit1 along with an intern from each team who split the patients .etween
them7 $here is a senior resident Eco,ering the house4 a,aila.le to support them if the) need it1 and
there4s a second1 or E.ackup4 senior to help out as well7 ;'s an ancient night nurse1 )ou4ll notice
that I make lots of references to the night shift in these articles - this is .ecause the night shift is
where all the real nursing in the unit goes on7 He) C Kust telling it like it is< >a)-shift nurses ma)
sa) that their shift rules C don4t listen7=
$he consult ser,ices are still a,aila.le at night C the anesthesia resident is a,aila.le ;and has to
.e called= for emergenc) intu.ationsI sometimes we will call the renal fellow for Guestions a.out
C55H management at night1 sometimes we talk to cardiolog)7 $he other night a urolog) resident
was paged to deal with a fole) pro.lem in,ol,ing hematuria C the point is1 there4s someone in the
house a,aila.le to deal with e,er) kind of pro.lem7 $hese specialt) ser,ices eFist for a reason -
)ou need to see that )our patient gets proper care777
5- What des Res"iratr* +hera"* d in the ICU%
2!o1 let4s see1 Chuck seems to .e going into '+>!1 and the) were ha,ing a lot of trou.le
,entilating him1 so we paral)*ed him C Noanne is on for respirator)1 and she4s .een gi,ing a lot of
good ad,ice a.out the ,ent settings1 so check in with her when )ou need toA3

&.,iousl)1 a large num.er of our patients ha,e trou.le .reathing7 $here are all sorts of
technologies and strategies a,aila.le to help them1 and it4s important to remem.er that
respirator) therapists are not people who 2Kust make ,ent changes73 $hese are the people with
the specialt) training to help the whole team make Kudgments a.out pulmonar) management7 If
)ou think )our patient is in trou.le1 the respirator) therapist is there to help )ou and the medical
team figure out what to do7 Use their eFpertise to help )our patient7
!pecific things )ou ma) find an ++$ doing for )our patientD setting up a ,ent1 making
recommendations a.out ,ent management1 gi,ing inhaled meds through the ,ent circuit ;make
sure that the) know )our patient has .een ordered for these1 and get them to sign off on the med
sheets=1 setting up alternate ,ent s)stems like face-mask ,entilation1 mask C6'6 or mask .i-pap1
high-flow &2 setups1 nitric oFide treatment s)stems1 helioF treatment s)stems - and if )ou4re
luck)1 )ou4ll get to watch them running an HCM& s)stem7
Here4s )our part in thisD make sure that there are clear lines of communication from the team to
respirator) and to nursing7 Changes in ,ent settings1 or in ,ent modes must .e entered into the
computers as orders7 Jou can certainl) get the team to write orders that gi,e )ou some leewa) C
such as 2Wean :i02 to keep &2 saturation greater or eGual to /#O3 C a.solutel) oka)7 8ut don4t
let things happen without making sure that decisions are .eing made properl)1 and documented
properl)7
,- Wh are the ther sta!! in the ICU%
2I hate working da)s7 I mean1 I know some of the staff lo,e da)s1 .ut there are so man) people
aroundA3
&ther specialt) ser,ices are a,aila.le in the ICU C pharmac) is a,aila.le for Guestions 2"9 (7
!ocial ser,ice is alwa)s a,aila.le1 and freGuentl) help us with famil) and patient issues7 utrition
7
rounds on patients and makes recommendations for appropriate treatment7 6h)sical therap)1
chest 6$1 &$ people all get in,ol,ed7
It4s complicated7 8ut the part that I like is the fact that all of these s)stems1 pointed like .eams of
light on )our patient1 are focused through the nurse at the .edside7 Jou are the one who controls
the flow of e,er)thing into and out of )our patient7
+eali*e that )ou ha,e entered a new world1 which in compleFit) is right up there with 2nuclear
su.marine31 and take the time ;it takes )ears= to learn how to appl) all these tools of )our trade7
8e patient with )ourself7
-- What are the rutines ! the ICU%
2?i,e me a second while I write these signs down from this paper towel - I get totall) lost if I don4t
get it down on the flow sheet right awa)1 .ecause then I forget what happened and when7 !ee1
here is where he got acidotic1 and then we started a .icar. drip1 and see1 when his pH got .etter1
we were a.le to wean his pressors - a little1 an)wa)A3
--1- What are the rutines ! the ICU%
$ime is carefull) structured in the ICU C o.,iousl) we use routines to help us organi*e our
acti,ities1 so that we can tell which wa)s the patients are going7 ' lot of this has to do with
recording informationD flow sheets1 med sheets1 intake and output totals1 la. resultsA
$hese routines form another part of )our set of toolsD learn to use the num.ers on the sheets as
indicators of trendsD 2Wow - look at how his heart rate has gone up during the da)7 I mean1 look1
)esterda)1 all da)1 his heart rate was in the -0s1 and since he spiked1 it4s .een in the 1004s1 and
now he4s a.out three da)s in the hospital1 and how long ago did the) sa) was his last drink? Jou
think he might .e withdrawing? &r is his rate up .ecause he4s hot? &r .oth?3 &rD 2Wow - look1 as
his temp came down he came right off the @e,o1 and his heart rate is down1 and his p&2 came
up7 !o ma).e his pneumonia and sepsis are getting .etter1 and we can think a.out eFtu.ating
him soon?3 &rD 2@ook1 his crit has .een dropping o,er the past two da)s1 and he4s .een $88
positi,e a.out 2 liters e,er) da)1 so do )ou think he4s actuall) losing .lood somewhere1 or is he
Kust getting diluted?3
--&- 'w d I use the !(w sheet t rgani.e $* ti$e%
$he hourl) ,ital sign check is onl) the .aseline for recording patient info C with an) change in
condition1 )ou need to start recording more freGuentl)7 $he idea is that if the patient does
something1 and )ou ha,e to make a change in treatment as a result1 like changing a pressor rate1
or a CMI drip1 - then )ou ha,e to clearl) document what the) did1 what )ou did to respond1 and
how the) responded to what )ou did7 !ometimes )ou ha,e to record ,ital signs e,er) fi,e minutes
until a patient sta.ili*es7 !ometimes )ou can4t e,en get to the flow sheets .ecause )our hands
are mo,ing too Guickl)D hanging .lood1 ma).e two or three units at once1 changing fluid and
pressor rates1 suctioning1 .agging C I4,e written signs on the sheets1 on m) scru.s C and then
transcri.ed them a little later7 ;8etter )et1 get some.od) to help )ou out7=
&ther routines in the ICU are Kust .aseline too C dail) F-ra)s happen in the morning for eFample1
.ut the) can .e ordered an)time necessar) C did )our patient suddenl) .ecome h)poFic? +ounds
happen in the morning C .ut if a patient .ecomes critical in the middle of rounds1 things ma) ha,e
to get fleFi.le for a while7 8ut the routines form the structure of all the num.er crunching that is so
important to figuring out which wa)s the patients are going7
'n important word a.out routines C nurses can often get compulsi,e in the ICU7 ;$he) sa) that
somewhere in the world1 there is a perfect Ko. for e,er) mild kind of cra*iness7= $his is actuall) a
8
,er) useful personalit) trait to ha,e in the unit7 Unless something critical is happening1 I alwa)s
enter a room at the .eginning of a shift and follow m) routineD look at the patient7 $hen the
monitor7 $hen the ,ent7 $hen the drips7$hen I *ero the lines7 $hen I adKust the alarm limits7
/A(wa*s #he#k *ur a(ar$ (i$its01 $hen I check when the last set of la.s went out C do the)
need rechecking now? $hen meds7 $hen $887 'lwa)s the same routine1 like clockwork7 $his wa)1
I don4t ha,e to ask m)self later C did I *ero the lines? Ha,e m) patient4s alarms not .een showing
his heart rate of 2"1 while I was .athing m) other patient1 .ecause I forgot to check the limits? I
know that I ha,e those .ases co,ered1 .ecause I rel) on the fact that I keep to a routine7
't the same time1 sometimes routines ha,e to go out the window7 Jou ma) find )ourself writing
down signs e,er) fi,e minutes1 or e,er) two hours if a sta.le patient has .een made a 2floor-
.oarder31 or )ou ma) .e calling them out to another nurse recording during a code while )ou do
compressions7 +emem.er that the routines are a set of tools - make them work for )ou7
I alwa)s ask precepteesD what is )our goal for this shift? 'lwa)s keeping in mindD 2What4s wrong
with this patient?3 C this will .e )our guiding idea among the forest of all the new eGuipment1
procedures1 meds1 la.s1 etc7 6riorit) setting should help )ou figure out what )ou need to .e doing1
and in what order7 's an eFample1 a ?I .leed C do )ou want to spend a lot of time doing a head-
to-toe assessment at first1 or do )ou want to make sure that the pressure is up1 the heart rate is
oka)1 the airwa) isn4t threatened1 and that )ou know when and what the last C8C was? Jou
should .e a.le to assess all that within a.out 20 seconds1 standing in the doorwa) at the
.eginning of the shift7 Jou can1 and should learn to do )our detailed assessment as )ou work
)our wa) through the first hour or two of the shift C what )ou o.ser,e will make more sense to
)ou as )ou get a feel for which wa) the patient is going7
$ake time to do the .asicsD get the ,itals written down e,er) hour7 ?et the meds in on time7 Make
sure the $88 gets done7 !end the routine la.s on time1 and eFtras when needed7 >ocument
changes in the patient4s condition on the flow sheet promptl)1 so that changes )ou make in
treatment are clearl) linked to what the patient is doing7

' few more words a.out the .asic routinesD $884s ;$otal 8od) 8alance C also called I and &
totals=1 are calculated e,er) siF hours1 and tallied up at midnight7 >ail) la.s should .e sent a.out
"-#am1 although other la.s o.,iousl) get sent whene,er the) need to7 &rders are re,iewed at
rounds1 .ut can .e updated at an) time7 +emem.er to check the computer at least e,er) hour or
so to check C if the doctors ha,e gi,en )ou ,er.al orders1 repeat them .ack to the doctor1 and
insist that the) get written into the computer the wa) the) were told to )ou7 I keep a sheet in the
front pocket of the flow .ook for to help me keep track C I can4t hold too man) things in m) head
an)more1 and the more I write down1 the .etter I can find the information when I need it7
+emem.erD ,er.als are reall) discouraged7 6olic) isD orders must .e in the computer .efore the)
are acted on7
$he last piece of routine that needs descri.ing is the shift report7 $he goal is simple1 .ut report
needs to .e more than Kust reading off the num.ers C )ou need to communicate two .asic thingsD
what4s wrong with this person1 and what are we doing to fiF it? :or eFample1 I might start reportD
2Uh1 this is a 2( )ear old man who went down in a nightclu.1 and was intu.ated at the scene .)
the paramedics7 $he) think he aspirated his stomach contents1 and now he4s on the ,ent with
lous) .lood gases7 He had a toF screen that was positi,e for H$&H of 23001 .en*os1 and colace73
;Creati,e<=
!o there4s the o,erall picture7 $hen go on to the detailed num.ersD temp is this1 heart rate is that1
ga,e $)lenol and heart rate came down to this1 temp came down to that1 pressure has .een so-
and-so1 weaned the eo to this --- )ou get the idea7 $r) to see the forest and not all those trees C
again1 to do that1 keep in )our mind the ideaD what is wrong with this patient1 and how are we
appl)ing the tools of the unit to make her .etter? $hat will guide )our report7 Use a routine1 ;some
people 2start with neuro and work their wa) downwards3 C .rain1 then lungs and heart1 then ?I1
then kidne)s= and tr) to do it the same wa) e,er) time C co,er the .ases1 s)stem .) s)stem1 the
9
meds1 the la.s1 the $881 alwa)s thinking of the .ig picture7 'irline pilots land a plane .) going
through a checklist1 e,er) flight1 e,er) time C so the) ne,er forget to put the wheels down7 '
routine method for report will help )ou the same wa)7
2- What d I need t knw a3ut the $nitrs%
2I know the patient is sick when e,er) channel on the monitor has something on it73
2-1- Shu(d I 3e(ie4e e4er*thing the $nitr te((s $e%
$he monitors are )our second maKor .edside assessment tool C the first is )our e)es7 'lwa)s look
at the patient first C the monitor ma) .e crisis-alarming for 5$1 or as)stole C .ut is the patient
smiling1 wa,ing at )ou? $he 02 sat ma) sa) 30O - is the patient pink1 and eating dinner? $hings
like that7 +emem.er that the monitor has no .rain7 ;!ometimes it seems like the doctorsAne,er
mind7=
2-&- What #an the $nitr d%
$he monitor has a screen that is di,ided into sections C each section looks at a different part of
the patient7 $he monitor can see a num.er of different thingsD HL? ;we usuall) ha,e the monitor
displa) lead II and 51 at the same time=1 pressures of different kinds1 &2 saturationA the
monitor can count respirations ;not alwa)s ,er) well=1 and can monitor the heart rate off an
arterial line or a sat pro.e7 It can .e set to .eep with heart.eats1 or not to C it4s a ,er) useful tool7
8ut use )our e)es first7
2-)- 'w des in!r$atin get !r$ the "atient int the $nitr%
$here are a lot of ca.les coming out of the monitor C the first1 which fits in the green slot on the
left side of the E.rick4 is the HL? ca.le1 which goes to fi,e ;or more= chest electrodes on the
patient7 $he ca.les with red plugs go into the neFt three slots1 and the) are for monitoring
pressures through transducersD arterial lines1 C56s1 6' lines1 etc7 $he .rown slot is for a cardiac
output ca.le1 that )ou use with a 6' line7 $he last slot on the right is .lack1 and is where the
nonin,asi,e 86 cuff plugs in7 8elow the row of ca.les is a .lue socket1 which is where the &2 sat
pro.e goes7
$he monitor has software .uilt into it that is supposed to recogni*e arrh)thmias C and there are
different le,els of alarms1 from Ewarning4 to Ecrisis41 that tell )ou if )our patient has done something
to alert the software7 &ften the crisis alarm will go off1 which is triggered if the monitor thinks it4s
seen as)stole1 5:1 or a run of 5$7 >o not get into the ha.it of ignoring the alarms Kust .ecause the
first four ones were from 2motion artifact3D the patient shaking the wires1 or scratching herself1
.ecause the neFt one ma) .e real7 ;'ctuall)1 the law of hospital karma sa)s that if )ou e,er
ignore an alarm1 it pro.a.l) will .e real7 $his is the same kind of thing as looking around and
sa)ing 2Nee*1 it4s Guiet tonight3 C almost a criminal act7=
2-4- 'w shu(d I rea#t t the a(ar$s%
'larm awareness is ,er) important in the ICU7 $r) to remem.er that if )ou hear an alarm of an)
kind go off1 no matter whose patient it is1 )ou need to start thinking a.out what it means7 @earn
what the different alarm sounds are7 $r) to .e aware that )ou ma) .e tuning things out1 especiall)
if )ou are focusing reall) hard on )our own patient7 If )ou hear a 3M pump go off C is that the
flush line for someone4s pressors? If )ou hear a minipump C is that the pressor itself? 're the
main arrh)thmia alarms going off in the hallwa)s?
10
Jou ha,e to respond7 Jou are not allowed to ignore an) alarm1 at an) time7 Jou can certainl) ask
the nurse assigned to the room if she needs help1 and she can tell )ou that she4ll get the pump in
a minute1 that it4s her potassium dose finishing up7 8ut don4t let alarms go un-answered7
't the same time1 remem.er that it does take time to learn what the noises mean and how to
prioriti*e them in )our head7 8ut what )ou want to a,oid is some situation like this ;I make these
up to sound particularl) awful=D alarms go off1 and for whate,er reason no one responds right
awa)1 the patient eFtu.ates himself1 clim.s out of the .ed1 pulls out his C561 and is found
.leeding from the site7 It is a critical part of )our ICU skills that )ou learn to respond to alarms
appropriatel)1 e,er) shift1 e,er) time7
' couple more words a.out the monitors C learn to find )our patient on the central monitor screen
in the hallwa)s7 @earn to reset the alarms using the mouse at the central screen7 @earn to change
the paper in the printers1 and respond to the low-le,el alarm that reminds )ou if the)4re empt)7
@astl)1 .iomedical engineering is alwa)s a,aila.le if the monitors gi,e )ou serious trou.le7
5- What are the di!!erent "u$"s used !r in the unit%
28ill sa)s that it4s sort of a .ad sign when there are more than siF drips runningAan)how1 Chuck
is on nim.eF at % for paral)sis1 and fentan)l at %00 mikes an hour1 which is holding him prett)
well7 He4s on le,o at 3# and neo at "00 C the) sa) to tr) to wean the le,o first and the neo
afterwards ;.ut the) told me the opposite on some patient I had last week=7 He4s on $61 and >#
with 3 amps of .icar. running at 2#0 an hour1 and he4s on an insulin drip at "73
Man) of the medicines we gi,e in the ICU are dosed .) micrograms per minute1 or in units per
hour1 or in milligrams per minute - which means that the) ha,e to .e gi,en .) pumps that deli,er
reall) precise rates of flow7
Jou4re pro.a.l) used to using the 3M pumps for things like heparin on the floors C here we use
them for almost e,er)thing1 .ecause )ou reall) want to .e sure that fluids are running at precise
rates7
&ne common use for them is to run what we call Eflush lines4 - these are lines that are usuall)
running saline at some fiFed rate1 sometimes L5&1 sometimes more1 .ut alwa)s at a fiFed rate7
$o these we add other infusion meds C often we4ll use the introducer for all our pressors for
eFample1 and a 3M pump will run the flush line that keeps e,er)thing flowing along7 We also use
these pumps to deli,er precise ,olumes for I5 .oluses1 or for slow timed meds like 'mpho8 that
run o,er se,eral hours C lots of uses7 Jou can also program them to run .ag miFes of pressors1
.ecause the) ha,e a Edose-rate-calculation4 function that )ou pro.a.l) ne,er .othered with on the
floors7
5-1- What are $i#rin!usin "u$"s%
$he pumps )ou pro.a.l) ha,en4t seen .efore are our s)ringe pumps C also called Emicroinfusion4
or Eminipumps4 C these are used for meds in s)ringe miFes that ha,e to .e titrated ,er) tightl)1
sometimes in increments of 10 mikes per minute or less7 $he)4re ,er) precise1 .ut remem.er that
if )ou change the flow rate on the flush line ;the)4re usuall) plugged into a flush line=1 then )our
deli,er) isn4t precise an) more7 @ikewise1 if )ou disconnect a med1 remem.er that the flush line is
still full of that med1 starting from the port where )ou unplugged it7 @ast week we couldn4t figure
out wh) a patient4s .lood pressure was still low after we4d unplugged the la.etolol for an hour C
then we reali*ed that the flush line was running at 10cc9hr1 and the drug had .een plugged in wa)
up the line1 so the patient continued to get the med1 as the line was still full of drug7 We took the
line down1 aspirated the line1 and the patient4s pressure .egan coming up within 10 minutes7
!)ringe pumps are useful C like an) other de,ice1 )ou ha,e to get used to them7
11
10- What are a(( the (ines ging int the "atient%
2!o oka)1 Chuck has a swan ;www7icufaGs7org96'@ines'pril0"7doc=1 he has a left radial '-line1 he has a
femoral Buinton on the right for the C55H7 He came up with like # peripheral I5s
;www7icufaGs7org96eripheralI5s7doc= 1 .ut he4s so swollen I couldn4t get an) .lood return out of most of
them1 so I pulled them - there4s one in his left antecu. that I4m running the .icar. through
.ecause it wasn4t compati.le with an)thing1 and it does ha,e a good .lood return7 I mean1 we4re
using e,er) port on the gu)1 and I don4t know where to run m) insulin dripA3
Jou start hearing a lot a.out 2lines3 as soon as )ou set foot in the ICU C there are se,eral kinds
that )ou need to learn a.out1 .ut the) ha,e things in common that it4ll help )ou to understand7
10-1- 'w des the (ine #nne#t the "atient t the $nitr%
$he thing to remem.er is that some of the lines that we use in the unit monitor one pressure or
another inside the patient1 continuousl)7 @et4s take the eFample of an arterial lineD an 2'-line3 is an
ordinar) 20-gauge I5 catheter that is put into ;usuall)= the patient4s radial arter)1 in the wrist
where )ou feel )our pulse7 ;www7icufaGs7org9'rterial@ines7doc= ow1 )ou want to see that pressure up
on )our monitor screen C how does the information get there? $he catheter is connected to a long
piece of clear tu.ing which is rather stiff C which connects to a de,ice called a transducer7
$he transducer is a pressure sensor C it Efeels4 the pressure as it ,aries7 +emem.er that with
s)stole and diastole1 the pressure in the arteries is going up and down7 $he transducer changes
what it Efeels4 into a ,ar)ing electrical signal that goes to the monitor through a ca.le1 where it4s
displa)ed as a ,ar)ing line1 o,er time1 going from left to right on the screen7 $his catheter-line-
transducer-ca.le-monitor-displa) setup is the same for e,er) kind of in,asi,e line that we use C
which makes it easier to remem.er how the) get set up7
10-&- What are thse in!(ated white 3ags !r6 that hang n s$e ! the "(es arund the
ICU "atients7 3ed%
In,asi,e lines often lead to pressuri*ed areas of the patient4s .od) C for eFample the arterial line
a.o,e7 If that catheter were attached to a regular I5 gra,it) .ag1 the patient4s .lood pressure
would dri,e .lood right .ack up that line until the .ag o,erfilled with .lood C )ou get the idea7 !o
the trick is to pressuri*e the line right .ack into the patient7 $he transducer looks at the pressure
coming out of the patient1 and at the same time lets a pressuri*ed flow go .ack towards the
patient at a.out 3cc9hr1 to keep the line clear7 Jou4ll see these setups on arterial lines1 monitored
C56 lines1 and 6' lines7 $he eFception is intracranial 2.olts3 C these use the transducer1 .ut are
ne,er pressuri*ed7 ;www7icufaGs7org9IC6Monitoring7doc=
10-)- Wh* d the* use that sti!! tu3ing !r the transdu#ers%
Here4s the wa) I understand itD )ou want the pressure wa,es to get to the transducer clearl)7 !oft
tu.ing a.sor.s the ,i.rations1 so that .) the time the) get to the transducer the)4re all flattened
out and meaningless7 !tiff tu.ing reflects the wa,es .ack into the saline inside1 so the wa,es get
transmitted to the transducer without ,anishing along the wa)7
10-4- What shu(d I wrr* a3ut when using these (ines%
' word a.out pressuri*ed lines C I4,e learned the hard wa) to check that the connections are
tight7 :or whate,er reason1 these lines like to gentl) unscrew themsel,es1 usuall) at a reall)
unpleasant time C for eFample I alwa)s check the place where the art-line stopcock connects to
the catheter tu.ing C the) lo,e to loosen themsel,es up7 @ikewise1 check all the places where
meds and infusions plug into flowing lines C a hu. can come loose1 and )our pressor will infuse
,er) nicel) into the .ed while )our patients4 pressure .ottoms out1 and )ou run around the room
tr)ing to figure out what4s wrong7 8e alert to wet spots in uneFpected places7
12
More things to watch out forD a(wa*s $ake sure that *u74e set the a(ar$ (i$its "r"er(*7
Make sure the lines are dated7 Make sure that the)4re le,elled correctl)7 Make sure the .ags sta)
pumped up to pressure7 Make sure that )our wa,eforms look reasona.le C )ou need to know if
)our 6' line has slipped .ack into the +51 for eFample7 Watch for .u..les in the stiff transducer
tu.ing C the)4ll ruin )our wa,eforms7 Use air filters .etween the .ag and the transducers for
patients on .alloon pumps ;on the root line=1 and for patients who ha,e a 6:& ;patent foramen
o,ale= C the idea .eing that )ou reall) don4t want patients to risk a .ig air em.olus into the arterial
circulation7 ice .ig .u..le1 right to the .rainA?
10-5- 'w shu(d I rgani.e the (ines%
eatness counts7 $his is not Kust the compulsi,e part of me talking1 ;well1 it4s partl) the
compulsi,e part of me talking= - suppose )ou follow some nurse into a room where a patient is on
siF infusion drips1 and the lines are running e,er) which)-wa) all o,er the .ed and the patient1
crosswise1 not la.eledAsuppose this patient gets into trou.le C where are )ou going to push )our
meds? &r if she4s agitated1 where are )ou going to gi,e her 'ti,an? !uppose she arrests C Guick1
which line do )ou use? 're )ou Kust going to guess? Is the person co,ering for )ou at lunch going
to guess? Lind of nast) to see )our .icar. line cr)stalli*e when )ou gi,e calcium through it7 ?et
into the ha.it of organi*ing the lines C take the time to check them thoroughl) at the .eginning of
the shift1 so )ou4ll know things are tight1 and straight7 If m) patient has more than three infusions
going1 I usuall) la.el the lines at the connector with the name of whate,er is going through them1
and sometimes I la.el the pumps too7
11- What kind ! (a3s d we send n the ICU "atients% ;www7icufaGs7org9@a.sUpdated7doc=
2$he last crit I sent was at %pm and that was "21 .ut I4m sure that won4t last1 .ecause I4m
empt)ing his Nackson-6ratts e,er) hour or so7 :or .lood< $he) want us to send C8Cs e,er) four
hours1 and coags e,er) siF7 'nd the insulin drip means we send chems e,er) two hours1 and his
last .lood gas wasn4t ,er) good1 so I guess )ou4ll .e sending a lot of la.s tonight73
We send a lot of la.s7 &.,iousl) the la.s ought to ha,e some clear relationship to what eFactl) is
wrong with the patient - .lood gases for respirator) patients1 hematocrits and coags for .leeding
patients1 etc7 When we admit a new patient from the HW1 we usuall) send off the .asic 2one of
e,er)thing3D C8C1 coags1 what some people call a Chem 201 a .lood gas if needed1 cultures as
needed7 We also send a 5+H stool swa.1 and a M+!' nasal swa. off for screening with e,er)
admission7 We send .lood gases with most ,ent changes or with an) change in the patient4s
condition1 and the same idea should guide )ou in sending other la.s as well C if )ou suspect a crit
drop1 send a C8C7
11-1- What d I d with the resu(ts%
$he thing a.out la.s isD follow up< If )ou treat a low LP on a patient with ectop)1 check it again to
see the response7 If )ou went up on the insulin drip1 recheck the glucose in two hours ;insulin
drips reGuire glucose checks e,er) two hours an)wa)7= If )ou transfused them1 send a C8C an
hour later7 !imple enough7
'.out .lood gasesD it takes a while to learn to interpret .lood gases7 ?et someone to help )ou
interpret them1 .ecause the) can mean lots of things7
1&- What is the "r#edure !r ad$itting a "atient t the ICU%
2I swear1 it was such a mess getting him in here C )ou know how the) are in the &+7 I don4t know
how the) get the lines wrapped around the patient4s .od) like that7 'n)wa) that took a while1 and
13
I4,e got some of the admission paperwork done1 .ut would )ou work on the checklist for me? I4ll
keep him as a primar)1 .ut I4m a little ner,ous a.out running the C55H aloneA3
How an admission goes depends on how acute the patient is1 and sometimes where the patient is
coming from1 .ut the priorities are usuall) the same7 $he first thing when the patient arri,es is to
Guickl) do a ,isual assessment7 Has he tolerated the transfer well? Is he .eing .agged? Is he
nice and pink1 or dusk)? !ei*ing1 comatose1 or smiling and wa,ing? 8leeding? 'lwa)s keep in
)our mindD what4s the admitting diagnosis1 what is wrong with this patient? Leep it simpleD is he
ha,ing a heart attack? 'sthma attack? 8rain attack? Liller tomato attack?
:ollow the routineD hook her up to the monitors1 slide her into the .ed1 start writing down ,ital
signs1 do an intake HL?1 .utA assess< Is the patient h)potensi,e? >oes someone need to go get
a pressor for )ou .ecause the patient lost his .lood pressure .etween the H+ and the unit? >id
)ou check the transport monitor to see if she was in a sta.le rh)thm on arri,al? 'ssessment
comes .efore routine C remem.er that nothing replaces )our e)e as a monitoring de,ice7
1&-1- Ad$itting !r$ the OR%
'dmitting a patient from the &+ is a little different - postop procedures follow their own routine7
$he essential point is that we do initial reco,er) of postops with the anesthesia person C the) are
responsi.le for super,ision of post-anesthesia reco,er)7
&nce the patient is in the MICU .ed and monitored1 and once the initial set of ,itals ha,e .een
taken1 the nurse takes postop report from the anesthesiologist7 Jou want to know eFactl) what
was done7 Jou want to know a.out total fluids in and out during the case1 the H8@ ;estimated
.lood loss=1 .lood products gi,en1 la.s sent during the case7 Jou want to know if the anesthesia
or intraoperati,e paral)sis was re,ersed1 and when7 When the last dose of pain medicine was
gi,en1 and what it was1 and how much7 Jou want to make sure )ou know which surgical team to
page if )ou ha,e Guestions7 $hen )ou ha,e to document ,ital signs at least e,er) 1# minutes for
the first hour7 I usuall) send 2one of e,er)thing3 la.s if the) weren4t sent during the case1 get an
HL?1 ask if the) want an) postop F-ra)s C after all this1 the regular ICU routine will usuall) do7
>on4t forget that the)4ll .e in pain when the) wake up<
1&-&- What are 83arders9%
!ometimes we ha,e patients in the MICU that .elong to other ser,icesD usuall) surger) of one
kind or another7 We take patients from .urns1 thoracic1 general surger)1 neurosurg1 neuro-med1
and once in a while an &89?J person who ma) ha,e de,eloped pro.lems7 $his is one of the
neat things a.out working in this particular unitD here )ou will definitel) get eFposed to the widest
possi.le range of patients and pro.lems7 We do it all7
1)- What d I need t knw a3ut gi4ing $eds in the ICU% ;www7icufaGs7org9Med$ips7doc=
2He went into rapid a-fi. at a rate of a.out 1(0 at a.out 2D30 this afternoon7 He actuall) kept his
pressure up with that rate1 so we hung a loading dose of 'mio1 and started a drip at 1 C that4s
another port tied up7 Is 'mio compati.le with an)thing? We can look in the computerA3
?i,ing meds in the ICU is definitel) different from gi,ing them on the floors C one of the .iggest
differences is the use of I5 pushes7 It4s true what the) teach )ouD once )ou push it in1 it4s gone1
and )ou4re not going to get it .ack7 !o think1 and recheck la.els .efore )ou push7 'nd remem.erD
in general1 push slowl)7 >rugs pushed too rapidl) can kill7 Check the drug references for
guidelines on how fast to push different meds7
Meds that we commonl) push include diureticsD lasiF1 diuril1 sometimes edecrineI cardiac medsD
lopressor1 digoFin1 ,erapamil1 sometimes adenosine ;I hate adenosine C 10 seconds of pure
14
terror=I sedati,esD ati,an1 ,alium1 haldolI pain meds in small doses like morphine C there4s a long
list7 Initial doses of some of these meds must .e gi,en .)1 or in the presence of a ph)sician7 :e
sure that *u knw what these $eds are a3ut 3e!re *u "ush the$; $he simplest
eFample C when )ou push lasiF1 the first thing I ask the new nurses isD wh) is the patient getting
this med? $henD what4s the patient4s L
P
? $hen1 what4s her 8U and creatinine? - the higher the)
are1 the harder it will .e to diurese her7 &r is the 8U high1 .ut the creatinine normal C she ma)
.e dr) to start with7 $henD will she need L
P
replacement? 'ndD is she ha,ing ectop)? ;Wh) do I
ask that one?= @astD did )ou empt) the fole) .ag after the dose so )ou4ll know what her output
reall) was? I know it4s a lot of Guestions1 .ut these are eFactl) the kinds of things )ou need to
think a.out1 e,er) time7 'fter a while1 )ou4ll find that )ou4,e noticed most of those things alread) C
)ou4ll ha,e put the picture together7 It does get easier1 .ut it takes a couple of )ears to get
comforta.le ;don4t get too comforta.le<= C part of )our Ko. is to .e patient with )ourself7
1)-1- What are "ressrs%
'nother group of meds that )ou won4t see much until )ou get into the ICU is pressorsD actuall)
there4s a ,aried famil) of drugs that come under the name of 2,asoacti,es3 C drugs that make
.lood pressure go up or down7 $here4s another :'B a.out these1 take a look o,er there for more
on the su.Kect7 ;www7icufaGs7org96ressorUpdate7doc=
1)-&- What ther dri"s d we use%
&ther specialt) drugsD unusual sedati,e drips like propofol1 or continuous .en*os like ati,anI
continuous opiates like fentan)l or morphine for painI paral)tics like nim.eF ;cisatracurium= or
,ecuroniumI antiarrh)thmics like amiodarone C these all ha,e their own attri.utes that )ou need
to learn a.out7 'n eFampleD paral)tic drips P stress-dose steroids Q serious .adness in the form
of m)opath)D the patient ma) not .e a.le to mo,e for Guite a while after the paral)sis is shut off7
'.out sedation and paral)sisD let4s see how clear I can make this7 @isten up1 nowD sedatin and
"ara(*sis are nt the sa$e0 If I e,er hear another nurse tell me that his patient was sedated
with nim.eF1 I think I4m going to sa)1 2Is that how )ou want us to sedate )ou when it4s )our turn?3
:ortunatel) the teams usuall) get this one right1 .ut for some reason a lot of the nursing staff get
a little confused a.out this7 If )ou don4t know sedati,es from paral)tics1 then )ou reall) do not
.elong in the ICUA oka)? ;www7icufaGs7org9finalsedationupdate7doc=
1)-)- 'w d I $ake sure I7$ gi4ing a(( these $eds #rre#t(*%
+eferencesD check )ourself freGuentl)1 and alwa)s check if )ou4re not sure7 &ne thing )ou4ll notice
a.out eFperienced ICU nurses is that we4re continuall) asking each other if this is right?1 is that
right?1 looking things up1 crosscheckingA seriousl)1 if )ou ha,e a Guestion1 get a definiti,e
answer .efore )ou proceed7 Check with )our peers1 check with the doctors1 check with pharmac)7
o.od) is perfect1 and two or three heads are alwa)s .etter than one7
14- What are s$e ! the tests that ICU "atients $a* ha4e dne in the unit%
2$hen of course the) wanted all sorts of weird films1 and of course the) had to .e shot in the
room7 $hen ultrasound was up looking at his gall.ladder1 - the) were talking a.out putting in a
percutaneous drain1 and then the medical student told me the) were thinking a.out a porta.le C$
scan C I Kust looked at him1 and I guess he reali*ed that I was a.out to snap like a twig1 .ecause
he left the room in a hurr)A3
@ots of tests get done in the unitD the commonest of course are F-ra)s and la. draws7 &thers
)ou4ll seeD ultrasounds and echoes1 porta.le C$ scans ;these are almost worse than the ones )ou
tra,el for=1 trans-esophageal echoes1 upper and lower endoscopies C )ou ma) .e needed for help
15
with these7 Jou need to know what the)4re for1 what the) showed1 and how to get the patient
through them safel)7
15- What tests are dne n ICU "atients that the* $ight ha4e t tra4e( ut ! the unit !r%
2!o of course then the team wants to know if the patient can tra,el to C$ scan1 and I Kust was not
comforta.le with that7 I4m reall) not sure that this man would sur,i,e a trip to the scanner<3
$he commonest test that reGuires tra,el is to C$ scan7 $he scanners are se,eral floors .elow us1
and )ou ma) ha,e to pack up )our pressor-and-,ent-dependent patient1 and roll him down the
halls and down ele,ators to get there and .ack7 $his can .e a trul) terrif)ing eFperience for the
newer nurse1 .ecause )ou are reall) it C if the patient decides to do something scar)1 )ou4re on
the spot7
15-1- 'w d I take a "atient t C+ s#an%
@et4s walk .riefl) through a trip to the scanner7 $he scanner tech calls and tells )ou that )our
patient was .ooked for an a.dominal C$ scan with gastrografin contrast a.out an hour ago1 and
what do )ou mean no one told )ou?1 and what do )ou mean the patient hasn4t had their
gastrografin1 and can )ou .e there in fi,e minutes?
&r at least it seems that wa)7 'nd this is a patient whose pressure has .een Kumping all o,er the
map1 and e,er) few minutes )ou4,e .een running in and out of the room dialing her le,o up or
down7 'nd her .lood gases are awful7 'nd she4s agitated1 and )ou know she4s ne,er going to lie
still in the scanner1 and ma).e she doesn4t speak Hnglish1 and come to think of it1 )ou4re getting
prett) agitated )ourself7
8elie,e it or not1 much of the decision a.out tra,elling for this test is a.solutel) )our call1 )our
Kudgment ;.ut run the situation .) the resource nurse too=7 It4s true1 this dilemma has to .e
referred upwards through the medical chain of command1 with the point .eing clearl) made a.out
)our reser,ations and fears7 Jou can alwa)s1 and legitimatel) insist that a house officer
accompan) )ou with the patient if )ou think the situation ma) .ecome unsta.le7 8ut )ou are going
to .e directl) responsi.le for getting the patient through this ordeal safel) C therefore1 the trip
must .e a controlled eFperience7 'nd )ou must .e the one in control7
:irst off1 I would ha,e no pro.lem asking that the test .e rescheduledD the patient needs time to
a.sor. the gastrografin1 and )ou need to sta.ili*e her .lood pressure as much as )ou can7 Jou
need to make a coherent plan a.out tra,elling with respirator) C are the .lood gases so .ad1 is
the patient so acidotic1 that )ou think the patient might arrest at an) time now? >oes this patient
need to .e am.u-.agged during transport? Jou need a sedation planD does the patient need to .e
sedated for the test? Is the patient intu.ated? >oes she need to .e intu.ated1 so she can .e
safel) sedated1 so she can .e C$ scanned? 'nd it would .e a good thing if some.od) would
please tell the nurse eFactl) wh) the patient is going for this test an)how? Jou4d .e ama*ed how
the practicalities of something that seems simple can completel) e,ade the minds of the doctors
ordering these tests7 >o the) reali*e that this patient has .een as agitated as a trout in the .ottom
of a canoe for the past siF hours?
$he point is that while )ou do ha,e to do )our .est to get the scan done promptl)1 )ou must do it
such that make )ou sure that )our patient will .e safe7 othing else will do7 'n)thing less would
.e negligence7 'nd )our legal responsi.ilit) is no less than an) doctor4s7 !o take )our time1 and
do it the right wa)7
!o1 now we4,e re.ooked the scan for an hour later7 ?astrografin doses are going in e,er) 20
minutes7 Jou4,e arranged with respirator) to transport the patient ;who is intu.ated - that helps<=1
and the CC$ has agreed to push the ,ent down to the scanner suite for )ou7 Jou4,e pulled the
16
team into the room1 and after ha,ing actuall) seen the patient tr)ing to leap out of the .ed1 the)
agree to let )ou run propofol for the length of time it takes to do the scan7 ;>id the) think )ou were
l)ing when )ou said the patient was agitated?= $his lets the patient start to ,entilate a little .etter1
and their .lood gas looks a little .etter1 and the .lood pressure sta.ili*es1 and ma).e this won4t
.e so .ad after all7
?et )our tra,el gear togetherD tra,el monitor with .atteries1 code drug tackle .oF1 porta.le
defi.rillator with .atter) C remem.er how to work it? 6ractice now and then C I mean1 )ou know
what I mean C don4t actuall) defi.rillate the .ed1 or )our co-workers or an)thing1 .ut make sure
)ou know how it works7 Make sure )ou ha,e gel with )ou C it should .e in )our tackle .oF7
&F)gen tank C check the meter to see how full it is7 H,er see a patient arri,e from somewhere on
an empt) tank? C well1 don4t .e the first<
$urn off the tu.e feeds and aspirate )our patient4s stomach contents7 'n aspiration e,ent from an
e,en partl)-full stomach .ecause )our patient had to lie flatA not good7 $urn off the insulin drip
for the trip7 $r) to tra,el with as few pumps and Kunk attached to )our .ed as possi.le C the fewer
lines )ou ha,e to tra,el with1 the .etter7 I usuall) disconnect and cap the c,p transducer1 lea,e it
.ehind7
eFt C unplug )our pumps and )our .ed1 coil up the lines1 hang them so the) won4t fall under
)our feet or the .ed wheels7 Jou can lie the transduced lines with their .ags right in the .ed neFt
to the patient C the pressures will read reasona.l) well at that le,el when the)4re connected to the
tra,el monitor7
?ot e,er)thing? Unlock the .ed wheels1 and mo,e off a couple of feet7 'n)thing left connected to
the wall? o? &ff )ou go7 +espirator) will .ag the patient7 Jour position is at the .ottom of the
.ed1 watching or listening to the tra,el monitor as )ou go7 What I do is to turn on the sat-pro.e
.eeper7 $his can .e set not onl) to .eep with each pulse1 .ut also to .eep in a higher or lower
tone if the sat should rise or fall1 so that )ou ha,e some idea of what the patient is doing1 e,en if
)ou look awa) to steer around corners7
15-&- What d I d at the s#anner%
't the scanner C again1 this is )our show1 )ou4re responsi.le7 $ake )our time as )ou get the
patient mo,ed onto the scanner ta.le7 Watch that )ou ha,e enough slack on )our lines C if )ou
don4t1 then stop the scan until )ou do7 >on4t .e afraid to ask the radiolog) staff to help )ou mo,e
eGuipment around1 and to stop the mo,ement of the ta.le to make sure that the lines will reach all
the wa) in7 6osition the tra,el monitor so that )ou can see it through the control room windows
throughout the entire scan ;ask to .orrow their .inoculars C or am I the onl) one?=7 Watch that
monitor C it alarms1 .ut softl)7 If the patient needs a pressor change1 tell the radiolog) people1 and
the)4ll stop the scan7 $ake the time )ou need to keep the patient safe7 Write down ,ital signs
during the scan to document how well the patient tolerated it7
>one? +ight7 8ack to the unit1 the same wa)1 Kust .ackwards7
' word a.out the .ig scar) thingC a code in the C$ scanner7 $his is reall) not an) kind of fun1 and
sometimes happens if a nurse is pushed into taking a patient down who ma) reall) .e too sick to
go7 Which is no help when )ou4re down there and it happens7 $r) to keep that possi.ilit) in mind
when the team pushes reall) hard for a scan reGuiring tra,el1 and make )our concerns ,er) clear7
$his is the situation in which )ou ha,e a house officer come to the scanner with )ou7
If the patient does code C )ou know what to do1 so do )our .est7 Ha,e the radiolog) techs call the
code on the phone7 Ha,e them call the unit for help7 !tart compressions C watch the monitor7 ?et
someone .agging the patient7 Identif) )our line for pushing meds7 >elegate as Guickl) as people
arri,e C get someone .agging1 someone doing compressions7 Jour position as the + who
17
knows the patient .est should pro.a.l) .e pushing meds1 and speaking with the resident running
the code7 Jou ma) .e surprised at how well things go7 ;$ake 'C@!7=
15-)- What ther s#ans d "atients tra4e( !r%
&ther scans off the unitD M+I is the .ig one7 $his can .e a scar)1 prolonged eFperience1 especiall)
with a pressor-dependent patient1 since )ou ha,e to run special long I5 tu.ing into the scanner
room .ecause the metal I5 pumps can4t go in there7 $he) do ha,e a .etter monitor for .lood
pressure now C it will read an art-line now1 instead of onl) using a nonin,asi,e cuff7 8ut pa)
special attention to )our pump setup7 6re-prime the long tu.ing with pressor .efore )ou go down
to the scanner7 $hen get the lines all set up1 Guickl) mo,e the patient into the magnet room1
reconnect with the long lines1 and watch the patient until their pressure is sta.le to )our
satisfaction7 When things look right to )ou1 the scan can go ahead7 Important point a.out the M+I
room C the "atient $ust #$e ut ! the r$ i! 3ad things ha""en0 +emem.er that nothing
ferrous can go into the M+I scanner room7 $here was a stor) that went around a.out someone
forgetting this1 at some hospital or other1 and a code cart apparentl) got ph)sicall) pulled up off
the floor1 flew through the air1 and got )anked into the magnet7 8ummer7
@astl)D angio7 I hate angio1 .ecause it usuall) means someone is tr)ing to .leed to death1 and it4s
a race .etween )ou hanging .lood1 the doctors tr)ing to find and plug the leak1 and the patient
eFsanguinating7 ;!ome nurses actuall) enKo) the adrenaline of this situation7 M)self1 I like a nice
unsta.le cardiogenic shock patient on twel,e drips and a .alloon pumpA= !ometimes )ou ha,e
to sta) and hang .lood at a frantic pace with the nurse in the suite1 sometimes not7 >o )our .est7
1,- What d I need t knw a3ut I< a##ess%
2!o ask the team C I don4t know eFactl) where we are going to put another line in this patient1 .ut
I need someplace to run anti.iotics1 and I don4t want to interrupt an)thing7 &h1 )ou know what1 I
think I can run some of these through the C55H circuit1 right? @et me ask LarenA3
$he) sa) that timing is e,er)thing in life C sometimes that4s true1 .ut in the ICU1 access is
e,er)thing7 Jou Kust can4t ha,e enough I5 access7 H,en a low-acuit) ICU patient C sa)1 a 2soft3
rule-out for an MI1 should ha,e two heplocks7 Make it three7 What if the) rule in1 ha,e ectop) or
chest pain1 and the one I5 )ou do ha,e turns out to .e no good? >o )ou want to fut* around
putting in another one1 or do )ou want to .e read) with a .ackup? !imple enough7
In the world of I54s1 si*e matters7 8igger is .etter1 and .igger is usuall) farther up the arms7 If )ou
think that a .enign-looking patient can4t suddenl) turn into a frightening ?I .leed1 and need rapid
infusions of .lood and I5 fluid C Kust ask an older nurse7 'nd )ou can4t run .lood through a 22
gauge .utterfl)7 Choose )our access goals with an e)e towards what4s wrong1 or what )ou think
might .e wrong1 with the patient7
1,-&- Centra( =ines:
I lo,e central lines1 .ecause )ou can run an)thing through themD fluids1 meds1 .lood products C
)ou can transduce them and measure C564s C the)4re wonderful7 ;www7icufaGs7org9Central@ines7doc=
I hate central lines - the) can .e deadl)D an undressed central line site can suck air into the
,enous circulation1 or pro,ide entr) for killer germs7 8e ,er) careful with these7
1,-&-1- Where shu(d the* g%
$he preferred site of central lines is somewhere in the neck or upper chest1 going for either an
internal Kugular ,ein or a su.cla,ian7 $he pro.lem here of course is that the .ig finder needle that
the docs use to insert these lines can easil) drop a lung1 especiall) if the patient is on a lot of
18
6HH61 and the upper lo.es of her lungs ha,e .een pushed up to the le,el of her ears7 $his
doesn4t mean the)4,e done the insertion wrong C it simpl) happens sometimes7 &r the line could
make a wrong turn and go up into the neck towards the .rain7 !o unless it4s a code1 )ou must get
a chest film to make sure the line is in the proper place .efore )ou use it7 ;>o )ou want to .e the
nurse who .ecame infamous for infusing pressors towards a patient4s .rain?= ' Guicker site for a
central line is the femoral ,ein C this tends to .e a dirtier insertion site1 .ut if )ou4re dealing with a
h)potensi,e situation1 and )ou don4t want to ha,e to wait for chest F-ra)s to start pressors C that4s
the place to go7
' trick of the tradeD remem.er that all of the great ,eins1 which is where )ou want )our central
lines to go1 ha,e arteries right neFt to them7 It4s alwa)s possi.le that a central line can go into one
of these .) accident7 If )ou4re not sure which ,essel the line is in1 hook it up to a transducer C
e,en in a h)potensi,e patient1 the ,enous num.er is alwa)s going to .e lots lower than the
arterial one7
1,-)- Shu(d I "ut in $* wn I< (ines%
M) own feeling has alwa)s .eenD the more )ou can do for )our patient1 the .etter7 I think that all
ICU nurses should .e competent and comforta.le with putting in their own peripheral lines C
central lines of course are left to the docs7 8ut I4,e .een in codes .efore where the ph)sicians are
working like mad to get a femoral or chest line in some poor patient1 while a nurse working on one
of the arms Guietl) pops in an 1--gauge1 stands up1 and sa)s1 2I4,e got a good line here1 folks73
1,-4- What d ICU nurses gi4e thrugh I<s in the unit%
We gi,e much the same kinds of things that patients get on the floors1 eFcept that we often gi,e
more1 and more Guickl) C such as .lood products in treating a ?I .leed7 We also gi,e rapid
infusions of I5 fluids1 and as discussed a.o,e1 we gi,e a lot of I5 meds1 some of which are
pushes1 and some of which are ,er) precisel) controlled drips7 It can ne,er .e stressed enoughD
3e 4er* aware ! what is ging thrugh *ur (ines7 $his sounds almost stupid until )ou reali*e
what would happen if )ou hung an anti.iotic through a line with le,ophed in itAnot a lesson )ou
want to learn twice1 much less once<
1,-4-1- Cr*sta((id:
We use all sorts of clear I5 fluids in the unit C I guess I show m) old !ICU .ackground when I
think of these as Ecr)stalloid41 an old name for them7 $he main point to keep in mind a.out I5
fluidsD )our goal is to keep careful track of how much the patient a.sor.s7 !ome units do this
hourl) C we do it e,er) siF hours1 and we do totals at midnight7 Jou ma) find that )ou ha,e to
keep running totals in )our head C as in ?I .leeds1 when )ou need to know where the patient is1
2net3 C that is1 total1 positi,e or negati,e1 at an) gi,en time7
1,-4-&- :(d "rdu#ts:
We gi,e lots of these1 and )ou4ll ha,e to pass a transfusion test .efore )ou can hang .lood7
$ransfusion reactions are Guite dangerous1 .ut we see e,en suspected ones onl) rarel)7
!crupulous attention1 e,er) single time1 to the rules of checking .lood products .efore transfusion
will keep )ou and )our patient out of trou.le7 H,en in the worst ?I .leed situations1 when )ou4ll
see two +s checking .lood for the one hanging the .ags in the room1 while mem.ers of the
team are running a.out getting the patient intu.ated1 placing lines - those two nurses will .e ,er)
calml) standing there1 carefull) reading num.ers off to each other1 co-signing slips1 num.ering
the .ags1 and passing them in for transfusion7 +emem.er C there reall) is enough time in an)
situation to do things right7 !eriousl)C neFt time a crisis comes up1 take fi,e or ten whole
seconds1 and Kust stand there1 and collect )our thoughts7 $en seconds is actuall) a long time7 Jou
could e,en take fifteen7 ;&f course1 people will look at )ou and wonderA=
19
' couple of things to add a.out transfusionD )ou can run more than one .lood product at once1
which )ou ma) ha,e to if )ou4re chasing a .ig .leed1 .ut )ou ha,e to get an order written sa)ing
so7
Jou can sa,e a lot of time .) using multiple-use transfusion filters7 &urs are orange C the) plug
into standard large-.ore tu.ing ;not transfusion tu.ing1 use regular I5 tu.ing=1 and )ou can run a
total of ten units through them C packed cells and9or ::67 ot platelets1 I don4t think7 6ut a sticker
on the tu.ing num.ered 1-101 and cross the num.ers off as )ou go7
If )ou ha,e a large-,olume .lood transfusion situation1 )ou can get an ice chest up from the .lood
.ank that holds all the a,aila.le .lood products that are closest to eFpiration C this will gi,e )ou a
larger num.er of units to ha,e on hand C a good idea if ?I thinks that )our recentl) em.oli*ed
,ariceal patient might ,er) well 2open up3 o,ernight7 ;www7icufaGs7org98loodUpdated7doc=
1,-5- I< $eds:
We make a lot of our own miFes in the med room C remem.er to use ,er) careful techniGue doing
this7 +emem.er the #O rule of miFing C if )our additi,e will eGual more than #O of the total miF
,olume1 then withdraw and discard as much from the .ag as )ou will .e adding in7 +emem.er to
check miF compati.ilities C some meds like nipride must .e miFed onl) in >#W1 for eFample7 Use
the reference .ooks in the med room1 call pharmac) if )ou ha,e Guestions1 check the I5 med
polic) .ooks1 check with )our co-workers C )ou get the idea7 >o it right7 $ake careful1 detailed
pride in )our profession7
1-- What are s$e ! the #$$n e$ergen#* situatins that #$e u" in the ICU%
2I was surprised that he was a.le to keep his pressure up when he went into the rapid ':7 $he
team said that if it dropped we4d cardio,ert him out of it1 .ut he did fine1 and the 'mio load went
in1 and his rate is slower now73 ;www7icufaGs7org98edsideHmergencies7doc=
1--1- S$e 3asi# thughts a3ut e$ergen#ies:
8efore getting to specifics1 let me make one Guick pointD take the time to figure out what )our plan
is7 $here is alwa)s time to think1 e,en in a code7 $ake that time1 and use it7 $here is no need to
get reall) scared C help is alwa)s at hand7 In fact1 )ou4ll notice that a well-run code is actuall)
prett) Guiet D no )elling1 no pushing1 Kust calm orders coming from the person running the
situation1 and stead) application of the .asics1 which do not changeD 'irwa)1 8reathing1
Circulation7
!ometimes it helps to think )our wa) ahead of time through a gi,en situationD for eFample1
suppose )our patient stopped .reathing7 :irst C 2'nnie1 'nnie1 are )ou all right?3 ;grin<= eFt C
call for help7 eFt? ?ot an oral airwa) hand)? ?ot an am.u-.ag? Hook it up1 insert the airwa) C
is the patient mo,ing air with .agging? ow C is there a pulse? Is he responding? What if his
name isn4t 'nnie?
ow C suppose )ou saw 5$ on the monitor7 Jou pelt o,er to the patientD is he smiling at )ou?
&nce1 a ,er) green ICU nurse ran o,er to where he saw 5$ on a monitor1 and forgetting to first
assess the patient for responsi,eness1 wellA he thumped the patient precordiall)7 $he sleeping
patient did not appreciate thisD 2What the hell did )ou do that for<?37 Which of course didn4t help
either1 after the nurse found out that the 25$3 was actuall) monitor artifact1 generated .) water in
the patient4s corrugated &2 mask tu.ingA &r it reall) is 5$1 and the patient reall) is
unresponsi,e? $hink the scenario through C should )ou thump her? 6ro.a.l)7 ;What does 'C@!
sa) a.out this nowada)s?= Call for help7 ?et an airwa) C know where it is? It reall) does get
easier after the first few times7
20
1--&- Cardia#/'e$d*na$i# situatins:
2He did drop his pressure when ?loria was with him downstairs )esterda) in the scanner1 and
the) tapped his .ell) C she is ama*ing1 she whipped him .ack up here1 and she called ahead and
got the &' to order up some .lood products C he4s got a standing order to sta) ahead something
like - units of red cells - and got them up and running with the team within ten minutesA3
1--&-1- '*"tensin:
$his is one of the commonest situations )ou4ll see7 $he Guestion to ask )ourself C and the team C
is simpleD wh) is the patient doing this? $he answer ma) not .e so simple1 .ut usuall) has
something to do with the three .asic parts of a .lood pressureD pump1 ,olume1 or arterial
sGuee*e7 $here4s more a.out this su.Kect in the :'Bs on pressors9,asoacti,es1 and 6'-lines1 to
help )ou learn to sort these issues out7 Meantime1 thinkD does )our patient need fluid?1 or
pressors?1 or is their pressure low for some cardiac reason ha,ing to do with rh)thm1 or low H:?
's )ou gain eFperience1 )ou4ll learn to figure things out Guickl)7
$he commonest mo,es )ou4ll .e ordered to make in a h)potensi,e situationD gi,e a fluid .olus1
usuall) !1 usuall) 2#0cc1 sometimes repeated7 +un the .olus right in1 either wide open on
gra,it)1 or set a pump at ///1 which will gi,e the .olus in 1# minutes7 Make sure the I5 site will
tolerate the rate7 If )ou use a pump .ag to infuse cr)stalloid rapidl)1 $ake sure *u "re-s"ike
the 3ag6 and get a(( the air ut C )ou don4t want that going into the patient when the .ag is
empt)7
Used to .e1 we could use onl) one pressor peripherall)D dopamine ;using what we call the
Eperipheral miF4 of 200mg92#0cc= can run up to 300mcg9minute through a peripheral line1 although
in a code1 )ou do whate,er )ou ha,e to do7 owada)s we can also use phe)nlephrine at a
concentration of 10mg in 2#01 up to a.out 300 mcg9minute7
+emem.er that drugs like le,ophed and neos)nephrine work .) causing ,asoconstriction C if )ou
run them through a peripheral ,ein1 and the med gets eFtra,asated into the tissue1 the patient
could lose an arm1 or at least end up with a reall) nast) wound C I4,e seen them skin-grafted in
the past7
1--&-&- Arrh*th$ias:
2I think the le,o didn4t help the whole situation with the a-fi.1 so ma).e we could change him o,er
to neos)nephrine instead73
We don4t see as man) lethal arr)hthmias as we used to1 for the simple reason that most MI
patients get clot-.usted nowada)s7 It was alwa)s the .ig 2rule-ins3 that generated most of our .ig
scar) arrh)thmias7 Jou will see them though1 and 'C@! is a ,er) useful eFperience to ha,e gone
through when it happens1 .ut it4s Kust one of those things C )ou ha,e to go through it a few times7
Jou should .e a.solutel) clear on the .asics of defi.rillation7 $he essentials don4t changeD
assess for unresponsi,eness1 call for help1 get what )ou need7 !ome people do maintain a
pressure with arrh)thmias1 some don4t1 so .e read) with a defi.rillator7
;www7icufaGs7org9'rrh)thmia+e,iew7doc= ;www7>efi.rillation7doc=
1--&-)- Nt->uite-s-s#ar* arrh*th$ias:
Jou need to .e familiar with these7 We see Kust a.out e,er) weird rh)thm e,entuall)1 .ut the most
common ones nowada)s are the ones that go with sepsis and pulmonar) diseaseD a-fi.1 rapid
and not-so-rapidI a-flutter1 occasionall) !5$s7 $r) to .e familiar ahead of time with the use of
adenosine1 metoprolol and ,erapamil1 and know the procedures for shocking a patient out of a-
fi.7 'nesthesia is supposed to .e present during electi,e cardio,ersions1 .ecause the patient
might go into something reall) unpleasant1 like 5:7 6ush the s)nc .utton< +emem.er too that
21
sometimes septic patients go into these rh)thms .ecause the) want to go fast C that4s their refleF
to tr) to maintain .lood pressure7 $hink carefull) a.out whether or not )ou should .e .locking a
refleF tach)cardia7
1--&-4- 8?(ashing9:
' sort of cardiac9respirator) Edou.le whamm)4 that we see sometimes in the unit is the infamous
Eflash4 of CH:7 $his is usuall) due to an episode of ischemia1 or fluid o,erload1 or .oth7 If )ou4re
,er) good1 and ,er) Guick and luck)1 )ou ma) .e a.le to actuall) head this one off with
aggressi,e treatmentD remem.er @M&61 for lasiF1 morphine1 nitrates1 oF)gen1 and position7 $hat
is1 diurese him1 gi,e him morphine for pain1 nitrates for ischemia1 oF)gen for ischemia9shortness
of .reath1 and sit him wa) up in a high :owler4s position7 ' pillow under each arm is helpful7
Watch the .lood pressure< ?et HL?s with the onset of pain9 angina9 chest pressure9 whate,er1
and get another one afterwards7 $he goal is to see that the ischemic changes on the HL? go
awa) with treatment7 I personall) think that ICU nurses ought to .e a.le to read HL?s on a .asic
le,el to see if there are .ad things happening7 $his is actuall) not ,er) hard C a :'B on this topic
was put together recentl)1 so take a look< ;www7icufaGs7org9+eadingHL?s7doc=
1--&-5-Cdes:
2&h s-word73
I hate codes7 Na)ne likes them7 Hach to their own1 I guess7 I4d rather do m) .est to head one off1
than pump some poor person4s chest7 'gain C the .asics appl)D take the time to think through
)our plan7
Jou can call a code whene,er )ou need to7 $here4s a code .utton in the room1 or )ou can get on
the intercom1 or )ou can lean out into the hall and shout C .riefl)7 Jour Ko. is simpleD get help1 and
start the '8C7 !imple as that7 ?et the airwa) open C oral airwa)1 Kaw lift1 am.u7 ?et the .oard
under the patient1 get the HL? machine hooked up1 start C6+7 Jour position should pro.a.l) .e
2pusher3 C as the nurse assigned to the patient1 )ou know where to push meds7 Make sure
someone is recording the meds for )ou as )ou gi,e them7 +esponders to a code will .e what
seems like e,er)one including !anta ClausD anesthesia1 the medical seniors1 the rest of the team1
medical students1 respirator)1 pharmac)1 nursing super,isors1 operational associates C I think
e,en securit) responds to a code1 to escort famil) mem.ers out of the room if necessar)7 $he
code E.oss4 is the medical senior resident - make sure that orders are coming from one source
onl)1 since this is not the time to ha,e contradictor) orders fl)ing from ,arious places7
urses from our unit also respond to floor codes7 In practice this is usuall) the resource nurse1
.ut it ma) .e another senior staff person7 I usuall) tr) to get in to the .edside and help to get
things flowing smoothl)1 although the nursing super,isor ma) .e doing this alread)7 &nce the
situation is sta.ili*ed1 )our role as a 2first-responder3 is done C check with the super,isors to see
where the patient will .e headed1 then come .ack to the unit7
1--)- Res"iratr* situatins:
2His sat dropped after he got here C I think the ,ec wore off postop1 and he .egan to get
as)nchronous with the ,ent1 and his pH went to (70% with a 6C02 in the -0s1 so we had to
paral)*e himA3
+espirator) distressD this is another common ICU scenario7 $he goal here is actuall) to .e
planning ahead C )ou want to tr) not to let the .eginnings of respirator) distress get awa) from
)ou7 If )ou can7 :or eFample1 if )ou think )our patient is going into CH:1 )ou want to .e all o,er itD
treating it1 assessing them for response to treatment1 documenting sats and .lood gases and lung
sounds Athe secret isD ha,e a plan7 If )ou think )our patient ma) need intu.ation during )our
shift1 tell the team so1 tell the resource nurse1 tell respirator)1 and tell )our co-workers7 Impending
22
intu.ation is something the medical teams ma) not want to hear a.out1 .ecause it indicates that
the patient got worse under their care C not what some aspiring residents want to tell the
attendings in the morning7 8ut )ou ha,e no less of a responsi.ilit) than the) do7
Common situations in the MICU in,ol,ing the respirator) s)stemD pneumonia1 CH: ;or .oth<=I
'+>!1 sometimes 8&&6 C this one is unusual1 .ut we see it enough to remem.er it7 $he letters
stand for 8ronchiolitis &.literans with &rgani*ing 6neumonia7 >isco,ered1 I .elie,e1 .) the
famous >r7 8ett)1 of the same name1 at the Warner 8rothers !chool and Medicine and 'nimation7
8&&6 is a tissue patholog) diagnosis that the) make .) doing an open-lung .iops)7 $here4s two
kinds of this actuall)1 the kind with pneumonia1 and the kind without C )ou want to ha,e the kind
with1 .ecause in cases where it looks like pneumonia pro,oked the disease1 then those people do
.etter7 6eople with Kust plain 8& do worse7 ow and then we see people with pulmonar)
h)pertension1 or pulmonar) fi.rosis C we work with a drug called flolan on the first group1 which
takes some careful watching and learning C the second group is sometimes .eing worked up
pre-transplant7
'gain1 guiding )our plan in sta)ing ahead of the patient4s condition is remem.eringD 2What is
wrong with this patient?37 I mean1 it seems o.,ious7 8ut )ou can get so lost in sat pro.es1 and
.lood gases1 and arterial lines1 and ,ents and ne.s and this and that1 and all the trees1 that )ou
totall) lose sight of the forest7 8asic ideasD does the patient need diuresis? !uctioning? e.s? 'll
three? Intu.ation? !ometimes )ou can4t a,oid intu.ationD do )ou want to wait until the last
minute1 or do )ou want to do it electi,el)? Use )our team-mates to help )ou make )our plan with
the doctors7
$here4s lots more information on the specifics of what we do in the unit as regards respirator)
matters in the :'Bs on 25ents and '8?s3 ;www7icufaGs7org9,ent:'B7doc= 1 and 2Intu.ation37
;www7icufaGs7org9Intu.ation:'B7doc=
1--4- I@ Issues:
2I sent cultures from all the lines as the) went in1 and there4s no urine to send1 .ut I guess we
could straight-cath him to see what he4s got7 Chris cathed him )esterda) and said he got 2.ladder
dust3A3
:or some reason I alwa)s lump I> issues in with the respirator) s)stem7 6ro.a.l) a .ad ha.it1 .ut
so man) of our infections ha,e to do with pneumoniaA remem.er that an infection can hide in
lots of places1 and )ou as the person at the .edside are pro.a.l) in the .est position to help
figure out where it is7 8e prepared to do a lot of culture-draws in the MICU7 Check with the team if
)our patient spikes a fe,er C she ma) ha,e .een Ecultured up4 that da) completel)1 or the team
ma) want a whole new set7
1--5- Rena( ?ai(ure:
2$he renal fellow said he reall) couldn4t call it one wa) or the other if Chuck4s kidne)s are going to
come .ack or not1 so I guess he4s going to .e on C55H for the duration7 How long do we keep
people on C55H an)how?3 ;www7icufaGs7org9C55H7doc=
We see a lot of renal failure in the MICU7 It can .e chronic1 or acute1 or 2acute-on-chronic31 and
we think a lot a.out how to a,oid making things worse7 's a primar) nurse1 )ou definitel) want to
keep )our patients4 8U and creatinine in mind7 &ne thing to remem.er is that the kidne)s are
,er) sensiti,e to .lood pressure C the) hate to .e underperfused1 e,en for a short time1 and will
sometimes turn right around and .ite )ou .) going into '$7 $his can take a long time to come
out of C weeks sometimes1 sometimes less1 and now that more and more of the nurses are
competent with C55H1 we do more and more of it7 C55H looks like the octopus from hell1 .ut it
reall) does sort itself out after )ou work with it for a while C all of us look at it in terror at first7
23
1--5-1- Ur(g* "r3(e$s;
Under renal failure comes urolog)1 I guess7 We don4t see man) patients with urological surgeries1
.ut we do see the occasional nephrostom) tu.e7 More importantl)1 .e careful a.out fole)s and
where the) actuall) are1 as opposed to where the) are supposed to .e7
;www7icufaGs7org9:ole)Catheters7doc=
$ipsD do not inflate the fole) .alloon on a male until1 1D the catheter has .een ad,anced all the
wa) to the J1 where the .alloon port comes off1 and 2D until )ou see urine in the tu.ing7 Use
similar precautions for women7 H,en if the catheter has ad,anced smoothl)1 )ou ma) ha,e to
stand there for a minute .efore urine starts flowing - or )ou ma) see it right awa)7 >o not force
the fole) in under an) circumstances7 Call the team7 If )ou aren4t satisfied1 speak to the resource
nurse1 and think a.out getting urolog) to come and look7 Inflating a :ole) .alloon an)where .ut
all the wa) into the .ladder can .e a disaster1 and can mean possi.le surger) later on7 'nother
o.,ious maneu,er that gets o,erlooked C is the fole) plugged? ' sharp nurse sa,ed her patient
from C55H recentl) .) changing a fole) and disco,ering that the patient4s kidne)s were working
after allA
' word a.out Murph) dripsD gra,it) drip onl)7 o pumps1 no wa)7 If the drainage lumen of )our
patient4s three-wa) fole) plugs with a clot1 )ou do not want that drip pushing fluid through the
other lumen1 into the .ladderA
1--,- AI "r3(e$s:
2I don4t think we4re going to .e a.le to use his gut for a long time7 I mean1 with that kind of surger)
plus all the fentan)l he4s on1 he pro.a.l) won4t ha,e a single .owel sound for the neFt week or so
an)wa)1 so it4s a good thing the) started the $6 right awa)73
1--,-1- AI :(eeds:
othing comes to mind under the ?I categor) Guicker than ?I .leeds1 which as )ou pro.a.l)
know come in two main ,arietiesD upper .leeds1 which are as I understand it a.o,e the p)lorus1
and lower ones7 We see plent) of .oth1 and we get to know the endoscop) fellows prett) wellD
the) come in and scope the patients1 then sclerose or .and .leeding esophageal ,arices at the
.edside7 8asic principlesD access is e,er)thing C the)4ll order 2two large .ore I5s at all times31 .ut
)ou pro.a.l) want to get the team to put in central access as soon as possi.le1 .ecause these
patients can reall) mo,e fast7 ' clue to trou.le comingD watch the heart rate7 H,en .efore a
patient drops 86 from a ?I .leed1 her heart rate will rise7 H,en an increase of 10 .pm from
.aseline gets me all ner,ous7 !end la.s as )ou think )ou need toD the orders are usuall) for a
C8C1 and ma).e coags after e,er) set of transfusions1 or for an) clinical change7 !end la.s e,en
if )ou suspect a clinical change1 and )ou4ll .e wa) ahead of the game7 ' second main principle
with upper ?I .leedsD think carefull) C should this patient .e intu.ated for airwa) protection? M)
feeling is1 .etter safe than sorr)1 .ut he)1 I4m old C do )ou think I worr) too much?
&ther ?I .leed scenariosD we see the occasional 8lakemore tu.e- a soft ? tu.e with inflata.le
.alloons that ?I will insert1 and use to tamponade .leeding sites in the esophagus or upper
stomach7 $his is held in place with a cord-and-pulle) traction setup that attaches to the foot of the
.ed C it4s a good idea to know where it is ahead of timeD it hangs on the wall in the eGuipment
room7
ow and again we4ll send a ?I patient to angiograph)1 where the) tr) to plug a ?I .leed from
inside the ,asculatureD the) use fluoro and d)e studies to locate the .leeding source1 and inKect
sterile gelfoam ;is that what the) still use?=1 and plug the .leeding ,essel from the inside7 &r e,en
more funD sometimes we4ll take the patient to angio for an emergent $I6! procedure7 $his
in,ol,es threading a line down the Kugular ,ein into the li,er1 and using a trocar ;think of a small
24
harpoon= to poke an opening to connect up parts of the hepatic ,essel structure C this opening
allows .lood to .)pass part of the stiff1 cirrhotic li,er1 and lets the portal circulation pressure fall1
therefore shrinking esophageal ,arices7 It4s eFactl) the same as a porto-ca,al shunt1 as I
understand it1 eFcept different7
1--,-&- =i4er ?ai(ure:
We deal with a lot of li,er failure patients7 !ome of them are pre-transplant1 some of them are
treata.le1 some not7 &ften the)4re transfusion dependent C .e ,er) aware of their heme la.
,alues7 We gi,e a lot of lactulose C we follow ammonias dail)7 8e careful with .lood draws C we
see lots of people with hepatitis7
1---- Neur(gi#a( situatins:
2His neuro statusD a.out the onl) thing I can assess is his pupils - the)4re eGuall) responsi,e at
2mm .ilaterall)7 'nd his heart rate goes up sometimes when )ou talk near him C actuall) it went
wa) up when his girlfriend was talking to him1 so ma).e he4s not reall) sedated enough under the
paral)sis7 I ha,e the 8I! on him1 .ut I4m not sure if it4s reading right73
H,er) patient is at risk for neuro9 mental-status changes while in the MICU7 We don4t get a lot of
the reall) acute neuro patients in the MICU1 .ut it happens once in a while7 Jou want to .e ,er)
alert for changes in the patient4s neuro eFamD an) change in the si*e of either pupil compared to
the other1 or change in mentation1 or strength of an eFtremit)1 calls for an immediate check-in with
the team7 We do some continuous sei*ure monitoring with HH? machines1 that are left hooked up
to the patient for a gi,en period of time7 We used to turn them on periodicall) so that the neuro
people could look o,er the strips in the morning1 .ut nowada)s the) use a computeri*ed HH? that
apparentl) stores the information for them7 Jou should know what a therapeutic dilantin le,el is1
what ,alproate is1 and )ou should know what .en*os are usuall) used for acute sei*ure acti,it)7
8I! monitors are the latest and the greatest in the sedation monitoring line7
1----1- What shu(d I wrr* a3ut%
$he .iggest thing we worr) a.out in man) of these patients is increasing intracranial pressure7
$he thing to remem.er is that the ,er) first sign of this is decreased mentation C it4s ,er) clear C
the patient suddenl) .ecomes hard to arouse7 'n) patient in the midst of a neuro e,ent who does
this pro.a.l) needs an immediate head C$1 and ma).e mannitol1 depending7 $he famous triad
;Cushing4s triad?= of dropping heart rate and respirations1 along with widening pulse pressure
;s)stolic heading up1 diastolic down= is1 as I understand it a late sign of increasing IC6 C )ou do
not want to let this de,elop7 $he goal of mannitol treatment is to shrink the .rainD doesn4t sound
,er) nice1 .ut it4s .etter than ha,ing it tr) to escape down through the foramen magnum7
$reatment with mannitol is titrated to the osmolalit) ;2He)1 what4s this gu)4s osm?3= le,el C
remem.erD high is dr)1 and the goal is usuall) something like 2greater than 31031 normal .eing
something like 2-0-2/#7
euro patients often ha,e tight .lood pressure goals C too high and the) might .leed1 or re.leedI
too low and the) might not perfuse7 $he neuro team will tell )ou what range the) want C )ou ma)
find )ourself titrating nipride or la.etolol to .ring a pressure down7 &r the other wa)D recentl)
we4,e seen pressors used to h)pertensi,el) perfuse ischemic .rain tissue7 +emem.er to run
nipride alone1 without e,en a flush line7 ;I sometimes flag the ports on the I5 tu.ing that has
nipride running through it1 so that no one will accidentall) plug in an anti.iotic=7
25
1----&- :(ts;
If )ou do ha,e a patient with a .olt C luck) )ou< Use the chance to learn all a.out them1 .ecause
we see them ,er) rarel)7 I alwa)s ask the nurses in the neuro ICU to come down and inspect the
setup to make sure e,er)thing is right7 ;www7icufaGs7org9IC6Monitoring7doc=

I mean1 neuro is not m) strong point1 and I4m not sure I4d know a .olt unless the) screwed one
into m) head1 .ut the essentials of the eFam will alwa)s ser,e )ou wellD if a patient has eGual
strengths and pupils and is telling Kokes one hour1 and is totall) out of it the neFt hour with one
pupil .lownA )ou get the idea7 Check with the team e,en if )ou think that there might .e1 sa)1 a
slight change in mentation C catching things earl) is alwa)s .etter<
1----)- A .e3ra; /A nursing student hears h!3eats ut the windw; @es he think ! a
hrse%1
' last neuro scenario that we see once a .lue moon1 .ut which )ou need to know a.out is the
infamous 2neuroleptic malignant s)ndrome31 or 2M!31 which is a rare side effect of antips)chotic
meds like haldol and *)preFa7 $his is when )our patient has de,eloped a reall) high fe,er C we
recentl) saw a patient hit 10( C in response to one of these meds7 $he) .ecome ,er) rigid1 and I
think their C6L .umps impressi,el)7 M! and its cousin 2malignant h)perthermia3 ;which shows
up sometimes in response to gas anesthesia= are .oth treated with a drug called dantrolene7
6rett) orange color7 Works ,er) well7 Nust something to put in the .ack of )our mind7
1--2- Bs*#hiatri# situatins:
2It sounds like he ma) .e sort of a tough character C I mean1 eating home-cured meat and
drinking moonshine C was that reall) true? 'nd that whole stor) a.out taking so much aspirin C
it4s hard to imagine he didn4t know that would hurt him7 !o ma).e we should ha,e a plan when
we wake him upA3
We ha,e a lot of patients who ha,e ps)chiatric pro.lems1 and )ou4ll see lots of patients .eing
treated with antidepressants1 or antips)chotic meds like haldol7 8e aware that haldol can prolong
the B$ inter,al to the point where the patient can ha,e dangerous arrh)thmias ;torsades de
pointes?=7 !omething to watch for7
1--2-1- O4erdses;
&ur mainsta) ps)ch situation is &>7 We see these regularl)1 and there are a couple of things to
keep in mind7 :irst is toFicit)D what did he take1 and is it tr)ing to kill him? !ome meds are
dial)*a.le1 lots are not C we gi,e a lot of charcoal1 we clean up a lot of stool7 ; ' lot of stool7=
$iming seems to .e most of the .attle in this one - how much did he take1 how long has he had to
a.sor. it? $hese patients must .e placed in leather restraints C ordered .) the acute ps)ch
ser,ice C and these can onl) .e remo,ed when the patient is 2cleared3 .) ps)chiatr) C not
otherwise7 @eathers come up with the patient from the HW1 .ut the)4re supplied .) securit) and
ha,e to .e returned there7
' word a.out restraints in generalD )our goal is to keep )our patient safe7 If )our patient is lined
up1 or intu.ated1 or Kust a .it confused1 )ou do ha,e the authorit) to restrain him1 although )ou
ha,e to notif) the doctors immediatel)1 and the) ha,e to enter an order7 $he order specifies how
much restraint can .e used1 for how long1 and wh)7 Make sure )ou understand the restraint
documentation policies1 and fulfill them7 H,er) time7
!peaking of o,erdoses1 this is a good time to .ring up the topic of weaning - we often run patients
on sedati,e drips for long periods of time1 and if someone has .een on morphine or fentan)l for
more than a couple of weeks1 the) ma) ha,e ha.ituated enough to reGuire careful weaning7 H,en
then1 the) ma) ha,e withdrawal s)mptoms7 $he .asic guideline that we4,e used in the past has
26
.eenD wean 2#O of the drip e,er) da)7 $his does not mean weaning in four da)s C it means
weaning 2#O of what4s running e,er) da)7 !o a patient on 1000mcg of fentan)l9hour will go to
(#0mcg on the first da) of the wean1 then #%2mcg the second da)1 then "20 the third1 31# the
fourth C alwa)s su.tracting 2#O of what4s up7
:or the tach)cardia and h)pertension that come with withdrawal1 we4,e sometimes used
clonidine1 either po or as a patch1 which apparentl) .locks a lot of the adrenergic release7 Works
prett) well7 Useful thing to know7
12 - 'w d I dea( with $* wn stress in the ICU%
$he first thing for a new person to reali*e is that coming to the ICU is like .eing a new grad all
o,er again7 H,er)one goes through thisD feeling scared1 feeling stupid1 feeling isolated7 ;$oo man)
of us still feel that wa)A=
Jou ha,e to remem.er that this is one of the ,er) hardest1 and most compleF Ko.s e,er in,ented
C as mentioned earlier1 right up there with 2nuclear su.marine73 6eople will point this out to )ou1
.ut it ma) not sink in until )ou find )ourself cr)ing in the .athroom for the third time in a week C
can )ou seriousl) think of a harder or more stressful Ko.? It in,ol,es .eing in 2crisis mode3 almost
e,er) da) C how man) people do )ou know out in the regular world who ha,e e,er seen
someone who ma) .e .leeding to death? If the) see something like that once in a lifetime1 it ma)
.e a stor) the) tell fore,er7 8ut )ou4ll see things like that e,er) week1 ma).e e,er) da)7 8e patient
with )ourself7 !enior staff + Nane sa)sD 2It takes a )ear Kust to learn which wa) to turn the
stopcocks<3
12-1- :eing s#ared;
!pecificall)1 as for .eing scared C read m) lipsD we all get scared7 !ometimes the older staff is
more scared than )ou are1 .ecause we know more a.out what might .e coming< If )ou4re in a
scar) situation1 there is onl) one wa) outD don4t let )ourself get isolated7 If )ou don4t ha,e )our
preceptor around an) more1 then talk to the resource nurse when )ou ha,e pro.lems7 !he should
know a.out them an)how7 If the resource nurse isn4t around1 go after )our team-mates7 8e a
sGueak) wheel if )ou ha,e to1 .ecause the patient won4t .enefit if )ou don4t speak up when )ou
think she needs something done7
12-&- ?ee(ing stu"id;
's for feeling stupidD look1 here we are surrounded .) uni,ersit)-le,el academic doctors7 How
could we not feel stupid?
8ut remem.er thisD residents spend one month out of each )ear in the unit1 o,er a three-)ear
residenc) C something like that7 Jou1 on the other hand1 are in the unit )ear-round7 Which means
that after one )ear1 )ou ha,e four times the ICU eFperience that a resident gets all told7 Jour
opinion counts7 >on4t forget that7
'nother thing to remem.er ;this should .e printed .ackwards on our foreheads so we can read it
in the mirror=D 2+here is n su#h thing as a stu"id >uestin;3 Watch the senior staff C after 1#
)ears1 we still check with each other constantl) to make sure we4,e got things right7
12-)- What d I d i! I $ake a $istake%
2I hung his 5anco at "1 .ut I got distracted .ecause he started .leeding from his Nackson-6ratts1
so I forgot to hang the other half of the dose C I guess I should4,e put it on a pump instead7 I told
the doctors1 and the) said it was fine1 .ecause with his renal failure that dose is going to go round
27
and round inside him for a long time7 8ut I felt terri.le1 and I know I4m going to worr) a.out this all
night73
$he onl) thing )ou can do if )ou find )ou4,e made an error is to let the team know right awa)7
$here is Kust no other wa) to handle it7 +eporting the error Guickl) will help fiF things the fastest7
8ut the worst part for man) nurses is feeling so .ad a.out it afterward7 Well1 think of thisD what
kind of nurse would )ou .e if )ou didn4t feel so .ad a.out it afterward? +emem.er )our mistakes1
and learn from them7 8etter )et1 learn from other people4s mistakes1 and a,oid making )our own7
8ut we are all of us onl) human7 Jou ha,e to learn to forgi,e )ourself e,entuall)1 or the Ko. will eat
)ou ali,e7 Ice cream seems to help7 Heath 8ar Crunch1 or ma).e Waffle ConeA
M) own wa) to a,oid mistakes is to .e eFtremel) s)stematic and compulsi,e1 .ecause I find that
doing things .) routine helps me remem.er e,er) single thingD I check m) med sheets e,er)
hour7 I check the computer for new orders e,er) hour7 ;?ood thing I4m not like this at home7 >o I
check with m) spouse for new orders e,er) hour? ot tellingA=
12-4- What d I d i! I !ind s$ene e(se7s $istake%
2Wow1 look7 !usie didn4t write down the ,ent settings1 and he4s on too much &27 I guess she is
human<3
$ell the team right awa)1 and check with the resource nurse a.out followup7 Make out an incident
report7 $ell the nurse )ou followed1 .ut .e gentle a.out it7 We are here to catch each other when
we slip on the ice1 not to hurt each other7 We are all we ha,e C we need to take .etter care of
each other7
12-5- What d I d i! I think the d#trs are te((ing $e t d the wrng thing%
$his is alwa)s a ,er) difficult situation1 and sometimes it happens7 ICU nurses tend to sum up
o,erall situations ,er) Guickl)D 2Will some.od) please tell me wh) the) insist on coding this
patient with li,er mets<?3 'nd )ou could make a good caseD that the nurses are so close to the
patients that we understand their suffering in wa)s the doctors don4t7 8ut )ou4d .e surprised C I
know I4,e .een surprised C to see more than a few of these patients that the nurses were sure
would ne,er1 e,er get .etterA actuall) lea,e the unit7
It4s eas) for us to fault ph)sicians for standing .ack C .ut ma).e it4s that distance that lets them
see what we don4t see1 up so close7
&n the other hand1 sometimes there4s a real difference in making a Kudgment call7 $he situation I
alwa)s think of is a team waiting too long to intu.ate a patient1 who4s increasingl) in respirator)
distress7 Clearl)1 if the p02 keeps going down1 and the :i02 keeps going up1 then where those
two lines meet on the graph is going to .e a plastic tu.e7 8ut the residents are sometimes
concerned that intu.ating a patient means that the) ha,en4t managed them correctl)1 which is
hardl) e,er true7
$he onl) wa) to work on a situation like this is to .e gentle and persistent7 8e a genuinel) friendl)1
insistent pain in the .utt7 Hnlist the resource nurse1 enlist respirator)1 and work on the team
steadil)1 .ut as nicel) as )ou can7 In a pre-intu.ation setting I would .ring the team in to look at
the patient with each .lood gas1 or e,er) time I had to .lind suction him1 and tr) to let the
e,idence con,ince them7 $hat wa) there4s no .ig ad,ersarial fight1 and no one can sa) that )ou
were unreasona.le7 Which helps<
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12-,- What i! I think the d#trs aren7t (istening t $e%
$r) not to get mad C getting into a fight will reall) make )our effort at persuasion tougher7 &n the
other hand1 what kind of caring nurse would )ou .e if )ou didn4t get mad? 'nd )ou can .e as mad
as )ou want to .e1 .ut if )ou dump it all o,er the team the) pro.a.l) not onl) won4t listen1 .ut the)
certainl) won4t listen7 !tead) application of cheerful pressure is reall) the onl) wa)7 2Uh1
Hildegard? I reall) do Kust ha,e to tell )ou1 and I know I4,e .een after )ou all night1 .ut I4m reall)
afraid that if we wait too long to intu.ate Mr7 :ink-ottle1 that we might ha,e a code situation on
our hands C I mean1 look at how his gases ha,e gotten worse in the past few hoursA3 If
Hildegard is smart enough to .ecome a doctor1 she should .e smart enough to listen to )ou7
12--- 'w shu(d I g u" the #hain ! #$$and i! the d#trs dn7t see$ t (isten t $e%
?entl)7 $alk to the resource nurse and see if she4ll go to .at for )ou7 If )ou and the resource nurse
agree that there4s a real pro.lem1 )ou can tell the team that )ou4d like to run the situation past the
house senior C this often helps resol,e these situations7 ;&nce again1 I4m descri.ing this as if
e,er)one onl) worked on the night shiftA= If the pulmonar) fellows are around1 )ou can drag
them into the discussion7 H,en the attendings ;sometimes especiall) the attendings= are usuall)
read) to listen to the concerns of the nurse at the .edside7 $he trick is - and this of course is the
reall) hard part - to sta) calm and friendl)1 e,en if )ou think the)4re acting dismissi,el) towards
)ou1 and Kust steadil) make )our case7 >ocument that )ou did so7 $ell them that )ou did7
12-2- 'w shu(d I in4(4e the resur#e nurse%
@et her know earl) on if )ou think a situation is de,eloping that might need inter,ention from
higher up the chain1 and keep her posted a.out de,elopments7 If )ou think something is
happening that ma) endanger )our patient1 let her know right awa)7 2@isten1 Mar) - I4m reall)
afraid for m) patient7 His pressure stinks1 and I think he needs central access right awa)A3
12-5- What d I d i! I think that $* "atient7s treat$ent is unethi#a(%
' lot of people ha,e trou.le with this issue1 and that4s .ecause it4s genuine7 We pro,ide a lot of
what often looks like futile care1 especiall) at the ICU nurse4s distance of siF inches or less7 It can
.e terri.l) frustrating7
$r) to .roaden )our perspecti,e of o.ser,ation7 Ma).e it looks futile in retrospect1 ma).e it looks
that wa) while we4re doing it7 I4m not going to sa) I don4t agree C of course I agree7 8ut the fact is
that the wa) our societ) is structured Kust now C the legal en,ironment1 our technical a.ilities1 the
incenti,e of the teaching hospital to teach C there are all sorts of forces at work that com.ine to
put )our patient in her .ed1 there in front of )ou7
Here4s m) feelingD I can4t change those social forces7 I can4t change the legal en,ironment that
makes families likel) to sue1 or not7 I can4t change the attitudes of a famil) who want 2e,er)thing
done3 for a patient with an o.,iousl) ;to me= terminal illness7 'nd no matter how .ad I feel for a
patient that I ma) agree is .eing made to endure a long painful course in the unit1 it is not m)
place to speak for them1 or to pre-empt what the) might ha,e wanted7 It4s their life1 isn4t it?
!o what I am faced with isD a patient in a .ed7 What to do? $ake care of them< ' Guote I read
somewhereD 2What then must we do? We must care for those that ?od places .efore us73 I mean1
it ma) as well .e me1 .ecause what I can do1 the difference that I can make is that I can ad,ocate
for that patient with all m) skill and eFperience1 so that their distress is minimi*ed1 and their
outcome C whate,er it is1 whate,er the) ha,e decided1 is the .est it can .e7 'nd it4s onl) the
nurse at the .edside who does that7 Who else is up in the middle of the night to hold the hand of
some d)ing person1 ma).e no famil)1 Kust the two of )ou1 and ma).e the ?reat ursing
!uper,isorA?
29
8ut it is a tough proposition7 $ough on us1 I mean7 $his is not a Ko. to take lightl)1 taking care of
people on the edge of life and death7 It has the deepest effects on )ou as a person7 $he suffering1
or e,en what )ou percei,e as the suffering of the patients1 can threaten to eat )ou up7
It can .e dealt with1 e,en if it seems o,erwhelming7 H,en if it is o,erwhelming7 ;'sk me how I
know7= Hach of us has to find her own wa)7 M) spouse has the same Ko. that I do1 and we ,ent to
each other1 and that helps a lot7 I ha,e two dogs1 who help a lot too7 8ut here4s one thought )ou
might hold in mindD e,er) da)1 when )ou walk out of that ICU1 don4t )ou look down at )our feet1
walking there under )ou1 and sa) to )ourselfD 2how priceless3? 'ren4t )ou glad that )ou can Kust
.reathe in and out on )our own? >rink coffee? :or me1 that4s the gift I get1 e,er) da)1 working in
the unit7 $he gift that onl) nurses get7 2Chop wood1 carr) water C how ama*ing<37 Well1 it is1 isn4t
it?
15- A wrd a3ut (e4it*:
>ear readerD it ma) seem to the un-initiated that there is some inappropriate humor in this article7
I think that an) nurse with an) eFperience of ICU nursing in particular1 or nursing in general1 will
tell )ou that if )ou can4t keep )our sense of humor C especiall) .lack humor C in a setting like an
ICU1 )ou are definitel) sunk7 Humor of this kind does not mean that an)one in,ol,ed is less than
serious C on the contrar)1 it is an effecti,e wa) of dealing with what is ultimatel) seriousD the great
matter of life and death7 's well1 there are ine,ita.l) descriptions of frustration with nearl) all
aspects of this Ko. C personnel1 tasks1 attitudes and institutions all come in for criticism7 $his is
also a kind of health) emotional ,enting1 and it needs to take place nearl) all the time7 6lease do
not get the impression that the opinions eFpressed in this wa) mean that ICU nurses are c)nical1
or d)sfunctionall) angr)7 'ctuall)1 the re,erse is true1 or the) wouldn4t .e there7 !o forgi,e us if we
seem a little .urnt around the edges7 $hanks<
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