Balls to the Wall (Or something like that)

After my super-stressful 14 hour shift without a lunch break, I believe I am entitled to feel E-X-H-A-U-S-T-E-D!  Last night I received that patient that no one really wants to get right at shift change--a massive head bleed.  Head bleeds mean hourly neuro checks, tight blood pressure control, calling doctors in the middle of the night, and emergency operations at say, 1145 at night.  In addition, I had the patient that no nurse ever wants to have -- crazy Houdini man who tries to kick the staff in the head.  You can only imagine what that means.   Many, many lessons were learned from this experience.

First, I learned secondhand last night how important it is to control one's blood pressure before you "blow a gasket."  My patient went to work with a headache, and ended up in the ER with blood in her brain.  When she came to us, she was only a few hours away from needing to be intubated, put on ventilator support, and rushed to the OR to have a chunk of her skull removed in order to evacuate the blood, thus decreasing the pressure in her noggin.   Subsequently, I learned the importance of good assessment skills and of notifying physicians promptly.      

Thankfully, all went well in the OR.  However, the most challenging part of my night was transporting this patient down to get a CT scan 3 hours post-op.   I think my pressure might have been as high as hers at that moment!  It took 4 of us in total--a respiratory therapist breathing for her by ambu bag, 2 techs pushing the bed and keeping me from ramming into walls, and myself, watching the monitor, lines, vital signs, breathing, etc--to successfully make the trip.   I think we spent, in total, an hour of commotion just to complete a 5 minute test.   It probably wouldn't have taken so long had I been like a boy scout, always prepared.  Lesson learned.   

At about the same moment as I get this patient down stairs, my other patient decided to play Houdini and attempt escaping from bed.  Not a good idea, dude.  I think at one point he even disconnected his trach from the ventilator tubing using only his teeth.  I didn't know that could even be done!  My neighbors were awesome at de-escalating that situation for me before I returned.  Needless to say, the rest of the night was quite challenging, as I had to try to find a good balance of sedation for this person who was either going to stop breathing from being "snowed" or was going to extubate himself in the most creative way possible.

For a while there, I wasn't sure who had been more stressful of an assignment, the head bleed/craniotomy or the Houdini.  Both had their fair share of challenging moments.  

There is a happy ending to this rant though.  I learned how to assist a doc to put in an arterial line to monitor blood pressure.  I refreshed myself on how to complete an admission assessment (since we rarely have to do them).  I successfully used Nipride to control blood pressure for the first time.  And, I learned how to prep a patient for the OR.  By the end of my shift, I had titrated my head bleed patient off of all sedation to find that she was able to look at me, to follow commands, and to move all of her extremeties.  Her entire prognosis had changed twice before my eyes.  As for Houdini, he did end up out of the bed, but only with the assistance of 4 willing strangers from physical therapy.   The best thing I learned-- it takes a village, but we saved a life and kept another from accidentally ending his prematurely.  How cool is that?