Saturday, June 30, 2012

Seizures, Stories, and Sleepiness!

If ever there was a potential for disaster, the title about sums it up!  First off, sleepiness for me is almost a recipe for disaster.  And then when you throw into the mix a patient seizing and several different stories from several different nurses, it makes for quite the interesting interaction.

The Background:
I just layed down to try and get a little sleep around 3 am.  The previous 11 hours of the shift had been really busy with 2 admissions and just a bunch of miscellaneous going on.  So I was grateful to get to try and rest, even for an hour or so.

Except that my brain wouldn't shut off.  And I could feel my eyes moving back and forth really fast every time I closed them.  Ever have that...or is that just weird!?

Anyways, about 40 minutes later, just as I was starting to doze, I get a page saying "She's seizing."

Umm, ok, first off...WHO is seizing!?  Second, what is going on??

So it was a girl with a known seizure disorder who came in with a viral URI and increased seizure activity.  OK- no problem.  I talked with the Neuro Critical Care team about an hour before, and had a well devised seizure plan.

The Plan:
Before walking over to the patient room, I wanted to wake up my preceptor (who by the way is just so smart and has done this PICU APN thing for so long that her brain can shut off in 2.2 she was out!)... I wanted to wake her up to go over my plan of action with her.

It was simple...go and evaluate the patient, make sure she is truly seizing, give 0.05 mg/kg ativan because we have it on the unit, and then order 20 mg/kg Fosphenytoin.

My preceptor loved the plan, asked if she wanted me to come, and I said no since the patient was fine.

This all happened over the course of about a minute.

The Action:
As I am walking through the labyrinth that apparently is called the hallway, I get a call from the nurse saying "She's desatting...are you coming soon!?"

To which I answered...Yup, right outside the door!

The Scene:
I walk into craziness...or my perception of it anyways.  The patient is definitely seizing.  And she is definitely satting 67%.  There is a nurse I have never seen before attempting to bag mask the child, but is obviously not effective at that moment.

Then you have the mom who is frantically pacing in the room and kept shouting "Is it OK that her sats are this long can her sats be in the 60' she going to be it OK that her sats are STILL this low!?"

And then you have the bedside nurse that paged me who is giving me the story in about 8 different increments, and not in chronological order as I would have appreciated : )

And then you have another nurse saying over and over "Do you want me to give ativan you want me to give ativan again?"

It was a mild form of chaos in that room.  And probably much less chaotic in reality than in my head, but being in the role of responsibility puts a whole other level of stress into the situation.

What I Wanted to Say:  SHUT UP!!! Seriously, everyone shut up!  Mom, I promise to answer your questions, but not until I get your daughter stabilized.  Nurse trying to bag, can you please do it effectively so that her sats are better than the 60s!?  And bedside nurse....WHAT IN THE WORLD is going on??  What do you mean you already gave a dose of ativan...that I hadn't even told you about yet!?

What I Actually Said:  OK, I need to understand better what is going on...when did the seizure start, what medications have been given?  I left shut up out of it, but I probably shouldn't have, because the mom was still shouting, and there were several nurses that kept asking "What do you want us to do!?!?"

The Ending:
I paged my preceptor for a little back-up help.  We repositioned the patient, bagged her up again, and finally her seizure stopped.  Ahh, all is well with the world.  The mom calmed down.  A couple nurses left the room, so it was much quieter.

And all of this happened in maybe a 6 minute time frame from the point of the initial page "She's seizing" to the end.

But it felt like 45 minutes of insanity to me!

Moral of the Story:
My preceptor told me several times that I handled the situation very well.  She said I had a well thought out plan, stayed calm during the time she saw me, and my outcome was effective and what we expected.

But I learned a few things in the situation that I want to improve on in the future.

1.) Turn my mind off.  OK, so this may not impact my situation directly, but I must say if I had been able to get in an hour nap prior to this craziness, my mind may have been a little bit less foggy.  Any ideas on how to do this is much appreciated!

2.) Take control of the situation.  I could omit the "SHUT UP," but next time I certainly need to control the environment better and quicker.  While I knew what to "do" because of my years of a bedside nurse, I couldn't effectively bag the patient while putting in stat medication orders, while hearing the full story and trying to calm the mother down.  Be more assertive. Take better control.

and finally, 3.) Seizures, weird mixed up Stories, and Sleepiness ARE going to happen.  It's what being a PICU APN is about.  It's the situations that get your heart pumping and the adrenaline flowing.  And yet our exterior is cool, calm and collected.

So it was a good night.  A night of learning experiences for sure.  And really, that's what this is all about for me.  Learning how to be a nurse practitioner.  Learning how to be a great nurse practitioner!

So if Seizures, Stories, and Sleepiness are what it takes to get me there, then bring it on!

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