On wound care and ‘being chill’

I slapped a fancy transparent waterproof dressing over the fish hook wound. I had found a few of these tucked in a drawer. I was kinda surprised they had them at camp since they certainly are not the cheapest wound covering but they are great. I liked them cuz they stuck (bit like wrestling with fly paper if you had to use a large piece) so they kept lotsa stuff out, but with them being translucent you could monitor just what was going on (meaning you would know when gangrene was beginning to set in so you could react quickly). Kinda handy!

“Well guys…I’m kinda wiped out. Do you wanna go down for that general swim thing again and just hang out on the beach with the other kids?” They all agreed.

“Nathan! Thank you again!” I said as I picked up my son and placed him on the counter top so I could wash his still sticky hands.
 
“No problem. It was really cool being of help. I have a question for you though. Did you have a class in ‘removal of fish hooks’ in nursing school, because that was impressive!”

I smiled. “Umm, nope. I just kinda came up with that during our paddle back. I learned about wound care and dressing changes in nursing school, but nope, fish hook removal was not a topic that was covered. Actually nursing school is pretty good at providing the basics, but then you learn so much on the job.” I thought back to my dressing change nightmare (click here for that posting) I had had a couple of nights ago. 

Working at the bedside in intensive care unit in a level one trauma center was a fantastic form of ‘graduate education’, shall we say? I got pretty good at managing lots of gruesome wounds. No one can say that nursing is not creative.


I would never say “I have seen it all”, but I had seen plenty. Gunshot wounds, motor vehicle crashes (pronounced like ‘vee hickle’ down here, y’all), falls (and not just down a few steps, like falls from trees, off a roof, etc), road rash (imagine your skin vs the road as you slide off a motorcycle), traumatic head injuries, and once a victim of a horse attack (yup..a horse). So, dealing fish hooks, busted fingers, and flip flop blisters was a delightful change.
 
“You seemed pretty calm too.” Nathan said.

“Well part of that was your calming presence, Nathan, but also my intensive care background was kicking in there.”

This ‘bedside university’ is also probably where I learned my outward appearance of ‘being chill’. Inside I might be jello with my thoughts racing (WTH is going on? What are my priorities? What are the ABC’s?), but outside I tried to appear as calm as a Hindu cow. I found that submitting to the drama never helped a situation, in fact, it distracted. 

I thought of one horrible code situation on a post operative CABG patient (coronary artery bypass graft) in an ICU. It, frankly, was a mess and the underlying cause was a lack of ‘the chill factor’. And all it took was one person. 

The culprit was a flighty nurse, Victoria. Vicky had a wonderful empathetic manner with the families. I don’t think she ever made a medication error. She was meticulous in her patient care. And….Vicky always made awesome brownies for our work pitch ins, which was a huge PLUS too. We knew her, we loved her but no one wanted her around when a patient was circling the drain, cuz she would escalate the tension…like ten fold. Best I could figure was that for some, unknown reason, she did not have confidence in her skills or perhaps felt that she was to blame when patients tried to die. So when things went south, Vicky’s stress levels went north, and we all suffered.

This ICU patient was slipping into cardiovascular shock on this particular evening. Unfortunately it was Vicky’s patient. A crowd of us ICU nurses rapidly surrounded the patient’s bedside as we all pitched in to get the saline boluses going and the vasopressor IV lines set up and running in order to try to pull this dude out of shock. A couple of nurse’s started to attempt to draw some vials of blood. Vicky was racing around the bedside, checking various drains and grabbing equipment. Her hair started to fall out of it’s perfect bun and sweat started to bead on her forehead. The ICU doctor, the cardiovascular surgeon and his fellow were STAT paged and got to the bedside with great haste. 

Now, the problem with this patient was that he had had open heart surgery. His sternum had been “cracked” as we say, for the procedure and then wired shut at the completion of the surgery. So…this is not the situation in which you would want to do chest compressions. That sternum is not stable enough for all that pumping. So what needed to happen was that we had to reopen this guy’s chest and perform manual compressions on his heart. Yes. That means, open him up, and grab the heart with your (gloved) hand and gently squeeze it to produce a pulse.

The surgeon called for a sterile gloves, a sterile gown and a scalpel. Oh and chest spreaders. I hate when they call for chest spreaders.

“You’re gonna crack his chest here? In the ICU? Not in the operating room?” Vicky squealed as she stopped in her tracks, hands full of bags of saline and IV tubing.

“Yes. If we don’t, he will die.” the surgeon said matter-of-factly. Vicky’s eyes almost popped out of her head. She paused for a second and then raced to grab the procedure cart that was twenty feet down the hall. The rest of us carried on in a calm and collected manner.

“Omigod. Omigod. Omigod. Omigod.” I could hear her chanting as she ran to get it.  As Vicky rolled it back to the bedside she bounced it off the walls three times while softly cursing. I ran to help her with the wayward cart. Once we got the cart to the bedside, Vicky started to frantically pull open each drawer looking for the supplies and throwing them on the bedside table. Meanwhile the surgeon was instructing the surgical fellow on the procedure. He was outlining a step by step approach as the fellow nodded his understanding.

“WHERE ARE THE CHEST SPREADERS?!” Vicky shouted as she stood over the opened drawers of the cart. We all jumped. I noticed the nurse, who was trying to stick the patient for blood, stopped abruptly and her shoulders sagged and then she took a deep breath and proceeded.

“Well if they aren’t in there, they have to be in the clean supply room. I will grab them.” I said as I ran/walked to the clean supply room. Indeed, they were stored on the ’emergency shelf’ and I was able to grab the tray quickly and bring it back to the bedside. 

The fellow and the surgeon hastily got gowned and masked up and put on sterile gloves. The fellow began to reopen the skin in a quick and efficient manner as the surgeon encouraged to go as rapidly as possible since the patient’s blood pressure was starting to drop more swiftly. The patient was definitely starting to look grey.

http://img.medscape.com

“Now we will need to have the code cart and the internal paddles ready to go, in case.” The surgeon called out over his shoulder. 

Vicky shot into action and ran to get the code cart, which was fifteen feet away down the other hallway. I heard the crash before I figured out what happened. Vicky had pulled on the cart, and forgot that the defibrillator on the top of the code cart was plugged into the wall. I had done this twice before too, but I figured it out when I felt the resistance and I stopped, unplugged, and then carried on. Vicky, however, with all her nervous energy had pulled on the cart with such force that the defibrillator flew off the top of the cart and landed on the floor.

The team paused briefly again, looked, shook their heads and returned to work. 

I ran to assist her in unplugging the machine and placing the heavy device back on top of the cart. Vicky was beyond flustered at this point.

“Deep breath Vicky.” I whispered as I pushed the cart and she pulled it walking backwards towards the bedside.

“Omigod I hope the defibrillator works now!” Vicky’s face was beet red and now there were small blooms of moisture in the arm pits of her scrub top. I pushed the ‘ON’ button and it fired up to life instantly. That was a relief.

At that point the surgeon had taken over the hasty dissection and the fellow was bent over the chest nodding. They both had their hands in the man’s chest. 

I stopped pushing the cart when we drew up to the end of the bed and I stepped over to assist in the set up of the IV pumps. I don’t know why, but Vicky gave the cart another big pull as she stepped backwards and then she stumbled. As she stepped backwards to regain her balance she managed to bump into the surgeon. With this, the surgeon toppled forward and managed to imbed the scalpel into the fellow’s index finger. 

I still recall this part in slow motion. At this point, the fellow raised his hand into the air with the scalpel sticking out sideways. He very softly uttered a very vulgar word in his surprised state.

http://sd.keepcalm-o-matic.co.uk

“Yup Nathan. As you know. ‘Being chill’ is pretty important.” I said, recalling Vicky’s rough day. “I am sorry that we occupied all your time. I hope that you can get your work done and that you don’t get into trouble.”

“Nah. It’s OK. I was just getting the fishing rods ready for fishing club today. I pretty much got the rods all untangled so now I just need to go to the kitchen to get some bait. And by kitchen, I mean the kitchen garbage cans.”

“No plain old worms for you?” I said wrinkling my nose as I had the mental image of Nathan rummaging through a garbage can of food leftovers which seemed less desirable then digging up fat pink worms.

“Nope. I have found that the fish particularly like the chicken or meatballs. I think it might actually be the Diana sauce that attracts them.”

Good to know.


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s