Sunday, December 23, 2007

Moments of Busy.

As you might of noticed from my last post that we are really not all that busy here in my RT Cave, but we do have our moments of busy and last night was one of them.

I get here at my normal time of 1830 figuring on a pretty decent night. I do the normal thing, put my coat and my food in my locker and fridge and then page the RT on shift to see if they need any help, usually it's a "Nope, I'll be right up.". Well not this tonight it was more of a "Could you get started on the treatments and meet me in the ICU, or I'll find you when I'm done." Ok still nothing to really get me thinking busy, I mean our treatment load is 2 QID's and one Q4, sure I can knock that out.

After I get those 3 really tough nebs (sarcasm) done I head off down to the ICU to see if my partner needs any help, well yep she does with a patient who is vented. Now I notice that she is bagging this patient and the vent is next to her and running, so I ask whats going on? She had been bagging this patient for over a hour now because the vent will not ventilate the patient. I go ahead and check out the vent to make sure it's working properly and passes all the self tests ... Yep works just fine, this patient is crap.

I go ahead and take over the bagging and get some report, this patient is septic in falling deeper into ARDS (Adult Respiratory Distress Syndrome) and is so tight that on Assist Control the most tidal volume we can get in is 30-50 ml's, not good. Alright next try is Pressure Control, great we have a Inspiratory Pressure up to 40 with no peep and can only get about 100-150 ml's VT, still not good.

My Partners pager goes off ... now what. Of course it's nothing good, we have another patient that I had done a neb on just about 20 mins ago now crashing so off she goes and there I am bagging a patient who cannot ventilate and is stiff as a board.

So it's now a Hour and a Half later, my hands are cramping and I'm still bagging and trying to figure out what to do, well dialysis is called in to get some fluid, almost 5 kilo's are wanted to be taken off, and hey here comes my partner with the other patient behind her while she is pushing a bipap machine, great what the hell is going on there. Turns out he has a reaction to a antibiotic that was just given to him that looked just like orange juice, now I'd think that would be rough going in on the veins. With further questioning I find out that the med he was give required you to premedicate the patient with Tylenol and Benedryl before it's administered, wow hardcore stuff there.

Finally 2 hours later my partner is able to give me some relief in the bagging area and the dialysis is started finally and a half hour later we are able to ventilate with PC on the ventilator, phew finally we can step back and relax a bit.

Now This patient pretty much stayed the same during the night. I ran three ABG's on the patient and from number 1 to number 3 the biggest change was a PO2 from 45-49 to good in the oxygenation department and spo2 was showing in the low 80's, but Doc said he was good with that and really didn't know what else to do because nothing was working.

Now getting a chance to think of everything that happened you start to notice the limitations of a smaller hospital. Heli-Ox would of been nice but we have none of that. PRVC mode might of worked but we don't have that on the PB 840 vent, there is VC+ which is supposed to be like PRVC but didn't really work to well as I tried it. Would of been perfect patient to transfer out but the weather was crap. So what do you do? Improvise and do the best with what you have, what else can you do, in a way it does make you use you knowledge a bit more versus using technology so much.

I must say I do like interesting patients and this one is interesting. Tonight I get the honor to having this patient again and so far nothing is improving, just a little increase in the saturation of oxygen area, but that could be due to the peep going from 12-16 cmh2o today. So tonight my last day before Christmas working I am still slow, with a Ventilator and a Q4 neb but as we all know anything can change at anytime.

Happy Holidays.

1 comment:

Freadom said...

Hey, you ought to give us an update sometime on this patient. What a very interesting case. I wish I had an interesting patient to write about, but nothing going on here.