A Case for Experience
I was stocking IV carts and making rounds on the nurses making sure they were doing ok …
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Our clerk called out over the radio, “Hey Dennis, a nurse from the MACU (Minor Acute Care Unit)[1] is wondering if you can go back there and take care of an EKG issue they’re having.”
I pressed the transmit button on my radio, “Roger that. Heading over there now.”
Such requests usually have to do with changing the paper on the EKG machine which is not that intuitive. So, I made my way over and all the while contemplated what kind of taco I was going to order from the cafeteria when I was done.
A nurse hears the doors mechanical arms operate and peeks out of her room. She smiles and waves me over.
Just as I suspected she says, “Hey Dennis I’m having a heck of a time changing out this paper.”
I smile and reply, “No worries. I’ll get you squared away.”
With the paper loaded I ask the nurse, “Would you like me to run the EKG. You know, since I’m here and ready to go.”
The nurse immediately replies, “Yes, be ready to run it continuous.”
I think, “Wait? What?”
Now, let’s back up a minute or so. When I entered the room, I smiled at the patient and wished her a, “Good morning.”
I’d not looked around to see who else was in the room. I could see human forms standing around, but it wasn’t my business. I was there to make as little footprint as possible.
So, when I heard the RN say to run the EKG continuous, I knew what that meant. A serious cardiac issue was taking place. As a nurse was placing the final EKG electrodes on this ladies’ chest I looked down at my screen and noticed her heart rate was well over 190 beats per minute. She was in SVT[2] and a medication named Adenosine was about to be administered.
Wait, what the heck did I walk into here?
Ok reader, time to pause.
Let me tell you about this medication. Adenosine is a drug that slows cardiac conduction, way down. Picture a reset button on your WIFI router. You push it and everything powers down and then after a second or two it typically comes back online and resets back to normal. This is what Adenosine does.
Now when you push this drug there are several items you want to have in the room. Chiefly, because there are times when the rhythm doesn’t start back up the way you’d like, and you must either shock to cardiovert the rhythm or begin CPR. I’ve seen this happen.
So, you darn sure better have a crash cart in the room and you want your patient on defib pads so you can shock them should the rhythm come back super funky.
Also, make darn sure you have suction on the wall ready to go in the event you need to take over the airway.
As I look around the room I see no crash cart, no LIFEPAK 20 defibrillator to shock the patient, no oxygen cannula in the nose, and no suction hooked up, ready to go.
Failure on all counts.
This startling fact causes me to look around the room and discern who is here.
There are two nurses from the MACU and then the Hospitalist (Admitting doctor for the hospital).
I had to respect their optimism. I mean by all accounts the medical staff were certain that everything was going to work out just fine with this cardioversion. Problem was I came from the ER and we’re notorious pessimists. We are certain things will go wrong so we prepare accordingly.
Truth be told I wasn’t worried for the patient because I noticed the RN was about to push the medication through a 20 gauge IV in the left hand. The “half-life” of the medication would cause the Adenosine to lose its effectiveness before it reached the heart.
Now, I’m a medic, not an RN and certainly no doctor, so I bit my tongue. I don’t want to look like a pompous jackass.
The doctor looks at me and says, “Ok, go ahead and run the continuous EKG.”
I reply, “Yes ma’am” and hit the button. The paper begins to pour out the side of the machine as it records the real time rhythm of the heart.
The Doc looks at the RN and says, “Go ahead, push the Adenosine.”
The RN repeats the order verbally and then pushes the medication very slowly so as not to burn the patient’s hand. She then nonchalantly grabs an IV flush which still needs to be removed from its plastic wrapper. After several seconds she wipes the hub of the port and injects the saline chaser.
Everyone looks at the monitor, but I don’t bother. I know nothing’s going to happen.
The doctor says, “Hmmm, ok, lets prep to do another dose.”
Ok, I can’t remain silent any longer. Medic or no, it’s obvious these folks are not familiar with this drug.
The trick is to offer advice in a way that makes it sound as if it’s the doctor’s idea.
So, I take the plunge, “Hey Doc. Since the half-life is so short on this medication how about I get you a large bore IV in the AC[3], hook up a 3-way stopcock direct to the IV catheter, and we then infuse the medication. I’ll immediately follow it up with a rapid flush of 30cc of saline. What do you say?”[4]
To her credit the Doc said, “Sure, that sounds like an excellent idea.”
She couldn’t help herself though and glanced down at my ID badge to see just who the heck I was.
I started a large bore IV in the AC and then hooked up the rest just as I suggested to the doctor.
I then explained to the RN, “Ok, you are going to put the syringe of Adenosine on that port, and I’m going to put the saline here on this other one.”
I looked up and the RN was smiling. She was having a blast learning something new. She said, “This is so cool. I’ve never seen this before.”
I cringed but didn’t say anything knowing the patient must be thinking, “Wait, what the heck did she just say?”
I smiled, put my hand on our patients left shoulder and explained to her, “We got ya. You’re in good hands. When the nurse pushes this medication, it’s going to make you feel super weird. Other patients I’ve had report that their chest feels flush for a quick second. It’s ok though. That’s how it’s supposed to feel. Your job is to lay your head back, take deep slow breaths and relax.”
I tap the patient’s shoulder which brings her attention to me. When she looks me in the eye I confirm, “You good?”
She nods her head. I smile, look over at one of the RNs and say, “When the Doc gives the order just hit that button that indicates ‘continuous EKG’ right there.”
She nods her head.
I now hand the baton back to the doctor, “Ok Doc, ready when you are.”
The doctor says, “Go ahead and start the EKG.”
The Doc waits a second, ensures the recorded EKG is coming out the side of the machine, looks at the nurse beside me and says, “Administer the Adenosine.”
The nurse repeats the order out loud and pushes the medication into the IV. I instantly flip the three-way valve and rapid flush the IV with 30ml of saline and then lift the patients arm up over her head.
We watch the monitor which almost instantly shows a change in rhythm. It flatlines for a second (normal), the patient makes a “woooaaahh” sound and then the rhythm comes back. It’s a beautiful normal sinus rhythm. Success!
The nurses were all smiles and talking about how cool it was to do that, “Thank you for coming in here and showing us how to do that.”
I said, “Hey no problem. Thank you for being so willing to learn from a lowly medic.”
They laughed and rebuffed my playful attempt at debasement.
Out in the hall the doctor asks, “What’s your background? Where’d you come from?”
I reply, “Oh yeah Doc, I worked twelve years in a Level One Trauma Center. Ten of those on night shift.”
The doctor smiles and says, “Oh, ok, yeah it all makes sense now.”
We laughed but inwardly I was worried. I mean if the admitting doctor and nurses are going to be pushing medications, they need to be aware of the risks. The room should have been prepped for a failure.
I ended up talking to my director behind closed doors and she agreed that a report needed to be given the CNO (Chief Nursing Officer) so she could advise the director of the MACU about education on such matters.
I was respectful of the nurses and knew they were compassionate and sharp. I really liked both of them and would often stop by to chat. Having gone through this experience with them made me respect these nurses even more.
Here’s why.
They were willing to learn from me, a medic, and that says a lot about their character. They could have viewed me as a “nurses’ helper” and dismissed me. However, in me they saw an opportunity to learn from someone who’d been dealing with these sorts of emergencies for a long time. They jumped at the opportunity, no matter whom the instruction came from.
Quite commendable.
Knowing their humility, work ethic, and eagerness to learn I have no doubt their patients of the future will be well taken care of.
For me, it was pleasurable to use my skills to help a patient while also training others, something I’m always passionate about.[5]
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[1] This is a unit of about eight rooms that borders the ER and is a place we would move admitted patients who were waiting for a room upstairs.
[2] Supraventricular tachycardia is an abnormally fast or erratic heartbeat that affects the heart’s upper chambers.
[3] The big vein in the bend of the arm.
[4] I believe the procedure has been updated at the time of this writing. I believe they just infuse into a large bore IV in the AC but straight into an IV line which is hooked up to a bag of saline.
[5] I would bet that since I retired the procedure for the administration of Adenosine has probably changed. This is how we did it back then. Things are always advancing to new and more efficient methods which is how it should be.
