Monday, May 3, 2010

That darn right ventricle!

A few weeks ago I oriented to open heart surgery patients. On my third day I was pretty much on my own. My preceptor helped me get my patient situated after the OR and then said, "Ok you're on your own. Come get me if you need anything." And she headed off to be the unit resource. I was actually quite proud of myself because I felt so much more settled the third time around. I felt like I had finally gotten a good handle on how to treat heart patients which was exciting to me!

One of the things I had noticed was that my patient's PA (pulmonary artery or Swans-Ganz) catheter had a funny waveform, which meant one of two things. The balloon on the tip was either inflated or the catheter was in the wrong place. It didn't look like my balloon was wedged so I assumed the catheter probably just needed to be moved a bit. At any rate, I asked our cardiothoracic fellow about it when he came to do rounds on his patients.
He looked at the catheter and decided that yes, it needed to be floated in a bit more. For those that aren't familiar with PA caths, here is a pretty good (although small) picture of what they look like going into the heart. The yellow line is the diagram of the catheter.

Now keep in mind, this is a catheter that is floating through the heart. As it floats through the differnet chambers, the waveform on the monitor changes which is an indication for the nurse and physician as to where the catheter is. When the catheter reaches the right ventricle everyone holds their breathe because the right ventricle is very 'ticklish' as we like to joke. If you stay in the RV for too long you can cause the patient to have PVC's or premature ventricular contractions. This isn't good because it can lead to ventricular tachycardia...a fatal heart arrhythmia.

So, the next thing I know the fellow is in my room, standing in front of me while I am in the middle of hanging a bag of KCL, and he's trying to inflate the PA balloon and float the PA catheter at the same time. Unfortunately this didn't work out too well and before you know it I start seeing PVC's all over my monitor. Within seconds my patient is in full on V-tach. Yikes! "Uhh, that's v-tach. You're in the RV!" I manage to mumble. At this point I'm terrified. After all, it is only my third heart patient and I'm not even off orientation yet!

In minutes our cardiothoracic attending shows up and starts yelling "Just pull out the swan! You can't inflate the balloon and float the catheter at the same time!" I feel completely frozen and I'm also physically stuck behind the fellow who is trying to float the catheter. Luckily, my preceptor jumps in and helps him inflate the balloon. They float the catheter into the pulmonary artery and the V-tach stops.
About a minute later I remind myself to breathe and the feeling in my extremities slowly begins to return. All in all there were a few good lessons learned.
A) Communication is key. When a physician mentions something about my patient or a procedure for any of my patients the first thing I ask is "When will you be doing this?" and "Do you need my help?"
B)Note to self: Don't mess with the right ventricle.
C) Always know where your code drugs and your crash carts never know when you might need them!

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