As the tele pack turns

8 Sep

Telemetry packs often look like this. We hook those wires up to patients and can see at the nurses station a continuous reading of heart rhythms and some even have blood pressure monitors as an added bonus. tele pack

Speaking of ICU nurses before I describe my last shift I want to mention a great blog post that introduced me to Nurse Sean: the post that summarized exactly how I was feeling at exactly the same time can be found here and the blog is here. Nurse Sean has been in my sidebar for awhile now and honestly I stopped clicking on his name for awhile but it appears that he is writing and I am clicking and reading.

Sometimes as a telemetry nurse things get crazy. Some of the patients are on the cusp of being critically ill while some are apparently stable, with unstable angina seemingly on the stable range of the shooting field. Some are admitted honestly by MDs to telemetry because we take blood pressures every four hours and they feel that the patient is closer monitored even if they do not need continuous rhythm strip analysis.

Resources. Working in a community hospital resources are a precious commodity to me, a telemetry nurse. And that is why I felt guilty after my last shift. I got report from the night nurse that a patient was admitted from the emergency department after going to the doctors office for being “shocked” multiple times within the last few weeks by his internal defibrillator: after interrogation it appeared the patient was having sustained ventricular tachycardia hence the AICD was doing its job. Anyway he arrives to the floor with a systolic pressure in the sixties. The night nurse gives a 250ml normal saline fluid bolus bringing him up to systolic in the seventies. I check his labs and see that his creat doubled since yesterday, and of course I was concerned. I assess the patient who is completely awake and orientated, only complaint was “a little dizzy” and his pressure is again in the sixties. The patient appeared to be in no distress at all: no pain, no tachycardia, no shortness of breath, clear lungs, making urine,  just a “little dizzy”.

Every nurse on telemetry it seems is so afraid to run in fluids: mostly because more than half our patients are in heart failure or have a history of it. Every nurse who has seen their patient go from breathing just fine to acute pulmonary edema will know the fluids can be frightening: but giving a dizzy patient with a blood pressure in the sixties only 250ml of fluids and calling it a night is not quite right!

So here I am on day shift with the maximum nurse to patient ratio of 1:6 ( a crime). Tending to this patient giving multiple 250ml fluid bolus over an over again (slipping in a little extra here and there)  when I really just wanted to run in the whole liter in an hour. Wasting my time doing the whole sepsis workup when internally I felt that the patient was just dry: but I was not willing to risk that assessment alone. When at the end of the liter going in (in 250 increments) the patient was finally transferred to ICU for the inability to maintain a decent pressure in spite of a liter of fluids: with scheduled anti-arrhythmic  medications to prevent further ventricular tachycardia that would lead to another “shock.”

Needless to say the patient received another liter in ICU: and was transferred back to telemetry the next day with a normalized pressure, and guess what? BUN and creat back to normal! and no other problems.

I honestly felt guilty like I misused a valuable ICU bed for some gentle fluid resuscitation. But in the end the guilt goes away because to many times, the call is not made early leading to poor outcomes. And to many times in community the ICU bed is not available, and transfers into ICU are actually triaged for the sickest to go in first while the other less sick patients ( but still critically ill) stay or get transferred in to telemetry waiting. When that happens the shift becomes a circus riot and your stable patients hardly see you.

So the census is back to normal. The revolving door to telemetry is open for monitoring. I started my last shift with 6 patients. 2 went home, 1 went to a medical floor, 3 stayed with me, 1 admission from the emergency room and transferred to ICU before shift change and 1 was stepped-down from ICU into telemetry: and that was just my assignment, my group: the story repeats for every nurse that shift and we call it: as the tele pack turns.


4 Responses to “As the tele pack turns”

  1. Sean September 8, 2009 at 14:06 #

    Hey! Thanks for the mention. And a great post!

  2. unsinkablemb September 21, 2009 at 01:43 #

    It’s my first time reading your blog. Found you through Change of Shift. Great work! Keep it up. Cheers! mb

    • seejanenurse September 25, 2009 at 00:11 #

      hey thanks! I followed your name to your blog! i like your blog too!

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