I had my ER day at one of the local hospitals that has a busy ER and a Trauma unit. I went 2 weeks ago, Wednesday, and was hoping for a lot of action. Unfortunately for me (and fortunately for the patients) that was not the case. The only things that were close to traumas, which were not, but were called "high index" because they did or could be hurt pretty bad, was one person who fell off of a ladder and a bicyclist who got hit by a car. They were both non-life threatening injuries.
I still enjoyed my experience. And I started my first 2 IVs ever, AND I got them perfectly on the first try. Of course the first one was with some pretty good advice from the nurse with how I should go in the vein. Also, on the patients who I started IVs, I needed to draw blood on as well, which I just used the line from which I inserted the IV catheter, but I was able to experience how to fill the tubes with blood. I had to help a nurse hold a 5 year old who needed his IV started. I was pretty impressed that I didn't cry, but I didn't!
Last week I had my ICU day. I didn't get to start any IVs or anything fun, but I took care of 2 patients with the nurse I was assigned to. One was REALLY critical. Very bad, and very sad. He was young, 50's got sick at home with what they thought was the flu. Came in after a week of being sick, having a hard time breathing and was admitted with pneumonia. He was admitted right into the ICU and needed to be put on a ventilator. He was in such bad shape, and he was fighting the intubation, he had to be heavily sedated. After some tests, he was found to be positive for Influenza A, which apparently is pretty bad. He was in Acute Respiratory Distress Syndrome (ARDS) which is also really bad. Apparently, if a person gets to the point of ARDS, it's not a good prognosis. Obviously, I am just going off what I've been told, I don't know much about ARDS yet. But at any rate, this guy was in bad shape.
Let me try to explain how bad. The ventilator has settings. There's settings where the machine breathes completely for you. Theres settings where the machine breathes a little and allows you to breathe some on your own. The machine was breathing completely for him. There is a setting for the percentage of pure oxygen you can give the patient. The air we breathe normally is 21% oxygen and that is enough to give us a good oxygen saturation (normal is 93%-100%). He was on 100% (and 100% oxygen for too long can start to become toxic, so thats not good either). Anything less than that, he would have lower oxygen saturations and his blood gases (sorry, that one is too lengthy for me to explain in one blog, ha!) would start getting bad.
Another setting, which I haven't fully learned about but will be for my Cardio final exam, is PEEP (positive end expiratory pressure). It has to do with the airway pressure needed to be maintained in order to improve gas exchange within the lungs. Any way, most patients on a ventilator are usually in the neighborhood of a PEEP of 5. Maybe 10 if things are bad. This patient was on 14. Basically, his lungs were so full of pressure and he was on the highest amount of oxygen, the only place to go from here was to get better or crash. Nothing more respiratory could be done for him. He needed to have a central line put in (so they didn't have to have 3 IV sites going and just keep this one site). However, this meant bringing the patient down to radiology to have it put in (this hospitals protocol). This guy was so critical, they could not wheel him to the department, in his bed, for fear of collapsing his lungs. It was terrible to see someone so young with no past medical problems, so sick and there wasn't much else for anyone to do.
I got to talk with his daughter, a recent medical student graduate who hasn't yet started her residency. She and her brother basically camped out in the ICU waiting room, day and night. She was thinking of changing her career to nursing because she saw how little time the doctors spent with the patient and family and how much the nurses did. I thought that was, and unfortunately, true. I do think there are a lot of GREAT doctors that do take the time for the patients and families and kind of get the short end of the stick with being stereotyped with all the others. I encouraged her to keep going and make a difference in the field.
Yesterday, after lunch, my clinical group went into the ICU. Every week we do this and whoever was in the ICU that week presents a patient to the group. My patient was still there. But now he was awake. I saw the daughter in the waiting room and we stopped to say hello. She told me how well her father is doing and that he has improved SO much. It made me so happy to see that it seems he's going to be alright that I kind of teared up a little leaving the waiting room. It just made me so happy to see them full of hope. I asked my friend to get his vent settings. He is now on 35% oxygen and his PEEP is 5. Even if you don't understand the numbers, you can see that 35% down from 100% and 5 down from 15 is a big improvement.
So there's my ER and ICU updates.
