he wanted a CVP set up and said that after that particular kind of surgery, patients tend to be really dry. (CVP stands for central venous pressure, and it is a measure of how much fluid you have. low CVP numbers mean you are dry and dehydrated-which can lead to increased heart rate. high CVP number means you have too much fluid-which can lead to other problems.) so i set up a CVP and the first numbers are, like, 1-2. low. sooooooper.
time for a bolus. a bolus is when you shoot a bunch of fluid into a person really fast. i started up giving a liter and 1/2 in an hour. it's kinda a lot.
didn't work.
fortunately the surgeon (who had probably been in surgery all day and still had to come back the next day) had consulted with the intensivist service to assist. so our pulmonologist was on board, who got a cardiologist on board.
so we cardioverted. i've written about this before, but a quick review. you push this drug really fast (adenosine) it stops the heart. the idea is that when the heart starts up again, it will be in a normal rhythm & rate.
its kind of like slapping somebody in the face who is freakin' out and telling them to SNAP OUT OF IT! only it's your heart, not your face. and it's not a glass of cold water, its 6 mls of a drug. again, for my non medical readers, the heart is that pumpy-beaty thing in the middle of your chest. it's kind of a big deal.
as it is for me, the guy essentially stopping your heart.
seriously, sometimes the things we do in nursing boggles my mind. i can't really tell you what boggling my mind feels like per se, but i think i've had my mind boggled. yup, pretty sure. boggle boggle boggle....okay, i'll stop.
so we pushed some adenosine.
heart rate; 153...............127.........................87.........................130................150...150....150...150...
mmm'okay. well, so much for that. granted, we could have pushed the drug a coupla more times, tried some higher doses, but the cardiologist was satisfied that the rhythm was sinus, and with the patient being asymptomatic, well, the rate was something we could live with. if it stayed sinus in the 150's. (sinus means that the heart is still beating the way it should, with the correct waves indicating the correct chambers of the heart are firing in correct sequence and blah blah).
at this point, with CVP numbers kinda where we wanted them (5-10), the heart was clipping along nicely in sinus at 150. if you're chuggin' along on a treadmill for a half hour, that's fine (depending on your age, fitness level, blah blah), if you are asleep in bed.......not so much. with her fluid level in the right spot however, the consensus was that we could live with it.
pulmonologist and cardiologist go back to where ever it is in our hospitals docs use to crash and curse the sounds of their pagers going off.
what with all the running around i did and having another patient besides, i hadn't had time to eat yet. i had brought something healthy with me, but the lateness of the hour, the crappiness of the shift so far, combined with the fact that nearly everybody else on staff that shift had gone and gotten something with fries, which i could smell as they ate them and walked past me from the cafeteria.........yeah, there was some fried food in my future. at this point it's about 0100. i go get some food, gobble it down so i can start charting,.......and my patients heart rate shoots up to 200.
son of a.........
i still had ketchup on my mustache and salt on my lips, dammit all.
time to wake up the docs, who were SOOPER thrilled to be called back for this, i'm sure.
mind you, the whole time, the patient remained asymptomatic. no signs or symptoms of distress whatsoever. no chest pain, no shortness of breath (SOB), nuthin'.
the docs convene. defecation hits the oscillation in other parts of the hospital. somebody codes on some other floor, which means i lost my intensivist. somebody else needed help in ER, so i lost the cardiologist. poor guy, he had to do a mini-research project in the middle of the night. he was reading notes and trying to determine the patients history because surprise surprise, the patient was an 'unreliable historian,' as we say in the biz. right before he leaves, he tells me, if patient continues, we'll have to shock.......
mmm'okay.
so round 'bouts 0430, the cardiologist calls to ask if said patient is still tachy (fast). yup. still fast. we've clocked the patient in the range of 190 to as high as 220. still asymptomatic.
okay, set up for electric cardioversion.
grab crash cart. grab etomidate (knock you OUT drug, short-acting). grab consent.
um, yes, could you sign here? yeah, this just means we're gonna electrocute you and try to stop your heart. uh-huh. and initial here. okay, thanks.
place paddles. one one right breast, one on left scapula (shoulder). connect to machine. respiratory therapist in room. charge nurse in room. sleepy family (spouse) in room. (um yeah, you're gonna have to have wake up, we're gonna zap your honey-nut-bunches of oats, that heart thingy problem is still going on).
joking with patient. joking with family. everyone in room smiling. doc gives order for etomidate. patient talking and laughing one minute, head rolled back the next. poke poke, hey are you awake? no response.
doctor; okay, hit the juice.
i'm clear, you're clear, we're all clear (making sure no one else is touching the bed).
zap!
flatline..............................................
then.........beep, beep, beep.
sinus in the 140's. we can live with that.
success!
phew, that was a long night.
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