A last minute trial

Today was my last day of orientation on day shift.  Starting Monday night, I'll flip to four weeks of night shift (11pm-7:30am) orientation before they cut me loose on my own.  In the past eight weeks, I've had patients die (who were DNRs and were supposed to die), and critical lab values to deal with... there have been codes on the floor, but none for any of "my patients" where I was really involved.  I haven't really had any true "emergencies". 

This morning I received in report that one of my patients, a middle-aged woman who had come in with new onset atrial fibrillation, was on a new anti-arrhythmic drug that we'd just started using in our hospital.  I'd only just recently gotten the education material on the drug, and was familiar with the protocol (which involved measuring QTc intervals on 12-lead EKGs after each dose and clearing it with the cardiologist before the next dose).  I knew that the protocol was to give 2g Mag Sulfate in 50ml normal saline over 10 minutes if the patient should develop a ventricular arrhythmia.  Fine, no big deal.  She wouldn't get her dose until noon, and when I went in to see her she was feeling fine, no pain, dizziness, shortness of breath, or palpitations.  She was gonna be an easy one!

She's sitting on the bed chitchatting with me, and I hear my name being paged to the nurses' desk over the intercom.  I excuse myself and go to the desk, to find the cardiologist and half the nursing staff staring at the telemetry monitor... I learn that my patient is in ventricular tachycardia.  Huh.  How about that.  V-tach is an arrhythmia that causes the heart to contract in a disorganized way, and if unresolved, leads to decompensation and lack of blood flow to the brain, heart tissue, and everywhere else.  The beating of the heart will degenerate further until it is simply quivering.  In other words, it is fatal if not corrected. 

I run into the med room, get the bag of magnesium from the med cart, prime the tubing, do my first two checks, and book it into her room.  Calm as a spring day, I explain to her that she's not tolerating the drug we'd been giving her for her heart rate, and that I needed to give her some magnesium through her IV to get her heart to beat in the right way, and that just to be safe we're taking her to the intensive care unit. She tells me she has a funny feeling in her head. I tell her to lay back in the bed and relax.

I do the calculation in my head, check it, and get the drip running.  I repeat back a verbal order from the cardiologist for IV Lopressor.    We hook her up to the portable heart monitor/defibrillator, and I run to the med room to draw up the drug, when I return the doctor tells me to hold off on the Lopressor for now, and he and I join our patient and two other nurses in the very crowded elevator down to the ICCU.  I jokingly tell her that it's all to do with the lousy cup of decaf tea that one of the other nurses made her this morning, she smiles.  We all pretend to not be looking at the tracing on the portable monitor. 

We get her into the room, hook her up to their telemetry, I find the chart to write the verbal orders, call for a stat 12-lead EKG, and chart a note documenting all that had happened in the last fifteen minutes.  I give a thorough and accurate report to the nurse taking over her care, give my patient's hand a squeeze and tell her she's well taken care of, and return to my work.  I learn an hour or so later that she converted back to sinus bradycardia.  I breathe a sigh of relief. 

I kicked ass.  I knew what to do, I did it calmly, safely, and quickly.  I was "the nurse", and I did my job without causing my patient to panic.  I feel prettty darn good about that.