Wednesday, September 5, 2012

APN in the OR!

Yes, I've been MIA.

But I've had a good excuse.  I'll give you one guess...

Yup, you probably guessed right! Jon and I went on vacation!

Well, it was a combo vacation and work conference for Jon, but it was full on vacation for me.

It was great!  It was 11 days full of nothing PICU related, no stress of trying to keep a little kid alive, and not overwhelming my brain with ridiculous amounts of new medical information.

But now I'm back to the real work.  Except, not my true real world.  I'm in the OR all week working with anesthesia.

That's right, an entire week of bag/masking, putting in LMAs, and intubating.

Let me tell you...there was about a half second that I thought about going to school to be a CRNA as opposed to an acute care nurse practitioner, and I'm SOOO glad that thought dissipated after the half second.

While successfully intubating a patient is an incredible feeling (or so I'm told because I haven't done it yet...I'll get to that!), doing that and giving gas/anesthesia to sleeping kids with very little interaction with the patient or family is SO not up my alley.

I love the PICU because I get to know my patients so well.  I get to form relationships with them and their families.  And that is so rewarding.

Nobody really leaves the hospital and profusely thanks their anesthesiologist...but they certainly leave thanking their PICU nurses and nurse practitioners.  That is not to say that their job isn't important (it's crucial to staying alive and asleep during surgical procedures!) but it's just very different.

So now that I've re-established my love for the PICU, let's get back to the successful intubation scenario.

I've spent the last 2 days in a satellite hospital OR which is super tiny.  There are 3 OR rooms- only 2 were being used yesterday, 1 today.  That means there are few cases each day.

And it means that it is all outpatient cases which tend to be "quick and easy."  So most kids don't get intubated.  A majority of mine yesterday got general anesthesia and just required a little bit of bag-masking, or even a nasal cannula.

I was able to place about 5 LMAs though which was good experience, and makes me feel more comfortable when I'm on nights in the PICU and more alone...if a patient is a difficult intubation I know that I can place an LMA!

So there was one patient today that could have had the procedure done with an LMA, but the anesthesiologist decided to fully intubate her for two reasons: 1.) so that I could have the practice, and 2.) because there is a propofol shortage and that's the medicine that he would have used if she wasn't being intubated.

So I got the chance to try to intubate her.  I had good technique with laryngoscopy and was able to visualize the vocal cords, but was unable to pass the tube.  The anesthesiologist asked if the vocal cords were open, and while I had a great view, I told him yes, but it looked really small.

He told me that the airway is small, so it wasn't going to be big, and try again. *Thanks, I know kids airways are small*

So I did try again, and once again could not pass the tube.

The anesthesiologist decided to attempt, and he said- "Ohhh...that's why...she's not fully muscle relaxed so her vocal cords are too compressed."  YUP- that's what I said...her opening was very small! So he muscle relaxed her, her vocal cords widened, and he easily passed the tube.

So I was frustrated at myself for not being able to get it...and then felt a whole lot better that there was an anatomical reason for why I was unsuccessful.  I was also really glad to have this experience in the OR, where it is an extremely controlled setting, there are no parents freaking out, and it is super quiet!

I have 2 more days in the OR this week, and I'm hoping to get a few more intubation opportunities tomorrow.  With only about 7 cases that may be unlikely, but we'll see.

So until this weekend, you can call me pseudo-OR-APN!  But I'll always be a PICU APN at heart!

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