And that's how I aged five years in 20 minutes

Today was my scheduled ECMO day. Lately it feels rather ridiculous to be on the team, since we hardly ever do ECMO in the PICU, there haven’t been many cases this year (when we’re first call) where we’re able to get in our hours on the NICU or CTICU, and our PICU ECMO team now consists of two RN’s on days, and two RN’s on nights. Realistically, if we ever did get a case, we wouldn’t have the staff to have a PICU ECMO RN for each shift.

Anyway, I walked in, and saw that I was assigned to Patient A. Which was fine. Except when I asked SS, she said that there actually was an ECMO patient on the CTICU, but that they’d decided to orient one of their own RN’s who’d recently completed the training. Which made the situation not fine. When I told SS that it had been months since I’d had any ECMO hours, she called over to the CTICU to try and swap out. However, they had another story of why it was impossible. Which left me with no ECMO hours. HG (the other ECMO day RN) commiserated with me, as she hadn’t done ECMO in three months. TL was also there, and hopefully as one of our managers, she will see to it that the first call ECMO RN’s get first priority to get our required hours on the pump.

The next (as if one wasn’t enough) challenge was to find an appropriate assignment for SB, who was precepting a new hire. SS eventually ended up switching my assignment for SB’s since her initial assignment was much too difficult for a first day of precepting on the unit.

So it was that I took report on Patient B. Who really was sick. Which was quite ironic, since I’d gotten half a report on her a couple days ago, until DD and I realized that it made more sense to switch assignments because he knew Patient B, and I knew his patient. Obviously, there was no way I was going to escape Patient B. The nurse giving me report started out by saying that Patient B had been on a trip to Mexico. And her tone told me all I needed to know. Turns out that Patient B had salmonella sepsis. And besides all the regular things that tend to happen with sepsis, her toes were totally necrosed, hands and feet cyanotic, and her kidneys were down, which was why she was on hemofiltration. Blistering all over her body, and an angry red rash over her trunk. Dopamine, epi, fentanyl and versed drips. TPN and IL. She needed an insulin drip, but there was no where to put it … as it wasn’t compatible with the drugs in her other lumens. Had to change the replacement fluid on the hemofiltration a few times because of labile electrolytes.

And then, I did it. Changing the dressing on her CVP line (which was right next to the Art-line, since her accessible sites were so limited), I was having trouble removing the tegaderm and steristrip dressing … steristripped supposedly because the line was already a little leaky. Although, both lines were sutured, making steristrips unnecessary. Anyway, I ended up cutting through one steristrip, and was able to extricate the intricate dressing. At first I saw a little blood, and I didn’t realize where it was coming from. A quick survey revealed that I had cut one of the three CVP lumens … the one with her pressors. A flash of panic, then I pinched it off and calmly (as best I could) called out for a helping hand. CW came in and handed me the clamp I needed, after which I transferred the pressors over to lumen 1 and got a doctor. Luckily (for me AND the patient), Dr. Metro was the only one on the unit, all the residents and fellows being in conference.

Dr. Metro calmly assessed the situation and said, “No problem.” Really, he is my favorite attending to work with. Besides being incredibly affable and knowledgeable and a good communicator, and having a dry wit, he also has a wife who on occasion sends baked goods to us on the weekends he’s on-call. We upped the epi a touch and changed the hemofiltration removal to zero, Easily enough, he popped in a 22g PIV into the left antecubital. I say easily because he actually comes to us from the anesthesia department. He then commented that this was an almost welcome diversion because it gave him something to do, and went to get supplies to rewire a line. We then upped the epi a little more, and when the pressure was sufficiently high, we switched the pressors to the LAC, and held the TPN, IL, fentanyl and versed. He rewired a new triple lumen CVP, and we switched everything back. Anxious titrating to maintain pressures. Withdrew a couple cc’s of waste from the LAC, and heplocked it. Redressed the CVP and art-line (no steristrips this time), and it was over. Returned the hemofiltration back to the original removal rate. I think I aged five years. The upside to this, is now she had a place to put the insulin drip, even if we didn’t know how long the line would last.

And so, there it is. The worst thing I ever did as a nurse. It really scared me. I’m so glad that it was Dr. Metro on, and that he was the only one actually on the unit … I would have hated to deal with any of the fellows, as much as I generally like most of them. And you can bet that I am going to be very very VERY careful with lines from now on. Steristrips only on unsutured lines. And keep those scissors away!!!