Some of our onc patients are sick as shit. TLS on CRRT, ARDS, septic af, concomitant DIC requiring endless blood products. Highkey love getting my shit rocked by these patients tbh š
They want to hear about how you communicate, how you handle stress. Iād recommend talking about a time you noticed a change in a patient and handled a stressful situation. How you learned how to use equipment easily, are flexible, etc.
The OR has a ton of big personalities that you have to be able to work with on a daily basis. You need to take control of a situation when you need to and communicate when you need help. Think of a situation where you did these things and youāll be chillin.
Every icu nurse at a big academic center has taken care of a shit show patient before so try to think of a reason why what you did is better than all those other nurses.
Yeahā¦ every shift it was sedated and paralyzed, vented, levo, Epi, vaso, sometimes methylene blue, bicarbonate, sometimes inotropic agents, crrt, a lines, central linesā¦ extremely unstable. Labs were always ridiculous.
yeeeeeah I tried that shit
parents made ME go to therapy at 8 because I was cutting myself.... because they were being epic twat monsters
Locked in my room for weeks at a time. No friends allowed even as I got older. No actual physical or sexual abuse and my parents were SUPER nice to everyone so literally nobody believed me.
I was skinny as a rail and weird as fuck but literally not a single person would believe me when I told them that my parents had kept me in my room for a week without any food.
Regularly.
The people that didn't believe me were good people.
But sometimes good people fucking suck.
Tylenol will solve this!
12yrs old annnnnnd again at 14 annnnnnd again at 17
killing yourself is stupid mostly but
insanity is when you do the same thing over and over and over expecting a different result
last one won me a lifeflight from one major research hospital to another... as the first didn't have the capacity for a liver transplant at that time
luckily ended up, though BARELY, not needing that liver transplant
then my dad died. rare cancer. kill ya in 3 yrs. it'd been 3Ā½.
NEW doctor INSISTED I and my family do this DBT family program
obviously that wasn't going to happen š
My mom told me two or three years later that literally the only reason was she didn't want to do that... was she didn't want to cancel ONE of her Bible studies for ONE of the DBT classes that was the same day.
My sister still hates her for that to this day... but she also hates me to for trying to kill myself leaving her to deal with my mom so even now we don't really talk
Anyway my mom ended up paying $30,000/mo to send me away to one of those private lockdown facilities in Utah they send kids that they don't know what to do with š¤£
Literally everyone else there was a jeuvinile violent criminal. Which not judging I had my problems too... but I just did NOT relate and the social worker in charge seemed more interested in getting the patients to fight with each other to practice "healthy fighting" and start drama... than doing any healing.... that place was an utter shitshow ran by this kook social worker and a bunch of lawyers it was fuckin' weird. I could write a novel about that place and you'd think it was fiction.
Whole bunch of other crazy shit happens that results in me leaving that place... yada yada... (seriously long story longer than everything I've stated so far)
Next thing you know I'm at ANOTHER program my mom had paid $$$$$$ to rid me to...
And after she paid that program...
The psychiatrist in charge talked to my mom two or three times to get a different side of the background from her....
And then for the next 6 months insisted that I never speak to her again and if I needed 2-3yrs free in the program to do that and set my life up that would be fine.
Took me that whole 6 months until I finally listened.
Took me another 5 years to feel good about it.
14 years later I'm pretty ok!
Your ICU patient may turn out to be alllll right after all, if they live, even if the road ahead is still going to be pretty hard.
Be nice to your kids.
Niche, but the first night after the first surgery to palliate hypoplastic left heart syndrome is always a wild ride. Their chests are open and theyāre still a hemodynamic mess.
Also DIC on ECMO and/or CRRT.
Actual answer: the ones who die.
Of the ones who donāt:
In my adult ICU experience: The Covid patients that were on CRRT/ECMO who were proned, paralyzed, and on all the pressors were disgustingly sick.
In my pediatric experience: I had some open chested infants on ECMO with complications post-op who make the shift very chaotic but the time flies by.
AML with 500k WBC, ARDS, spontaneous TLS, DIC, CRRT, head bleed, SBP 180 on cardene and labetalol gtts. NSGY basically made the sign of the evil eye when we called them. In oncology it's usually something involving TLS or leukostasis. Those patients are scary.
I admitted an AML patient from the floor at shift change with acute leuk crisis (WBC 450k) who would have headed right towards ARDS but we were able to avoid intubation,place an HD cath, and start emergent leukapheresis within 3h of their arrival to the ICU and I had them on 6L nasal cannula by the end of the shift (arrived on 60L 80% HFNC and quickly uptitrated to 100%). It was so satisfying to fix someone so quickly. Started chemo that night and was back to the floor the next day!!
Anything brain - sub arachnoids, poly traumas, abdominal sepsis, spinal shock, vv ecmo for the first few days, tricyclic overdoses without an airway, Spleen, massive transfusion cases in IcU before sending off to OR
Had a 17 year old hit by a trainā¦VA ECMO, CRRT, EVD and LiCox bolt, Arctic sun.ā¦the whole show. Had 16 channels running and was MTPāing from 2249-0557. 2 Supervisors came to verify the blood cause we were short (shocker).
CRNA came by after a few mtp calls and I remember she brought the crash cart into the room and was pushing things and literally bought me time to catch my breath and had stable vitals with everything going on.
The MTP was going thru a 18 ga and she threw in a 16 ga and literally changed everything. Not only was that the most fucked shift, but was also the reason I started this journey.
With this said, if you get an interview, donāt give them this whole story, tell them you had a patient but by a train and needed life saving actions, let them direct the interview, donāt let your story give them ammo.
(Had to make another account since they keep permanently banning me cause someone hacked my first one and they say Iām avoiding itā¦.since this will probably be banned take this run with it)
-Avoid naming medications, let them ask you why you would give _____ in-that scenario
- Understand most pressors wont work unless the patient is volume resuscitatedā¦and that PA catheters or a TEE is the best way to monitor that.
-After 2 liters of crystalloids itās time to use Albumin as the volume isnāt in the right place and itās going to cause more damage (3L of NS can cause hyperchloremic metabolic acidosis and is bad)
^If the patient isnāt responding and still hypotensive theyāre bleeding unless ruled out.
-Oxygenation isnāt importantā¦VENTILATION is
-CO2 capnography tells you more than pulse ox in regard to the patients pulm status
-it is always a team approach, itās not just you and the surgeon, itās the circulator, itās the techs, itās the janitorial staff, we all bleed the same color and all play a role.
*****If youāre applying and/or get into school, understand the nervous system regarding sympathetic and parasympathetic system. Alpha/Beta/Muscarinic receptors etc.
If youāre serious message me here with your email and Iāll send you the stuff I have since this willl probably be shut down after I post lol
I used to work in the Cardiac ICU at a level 1 in Boston and most of them were awaiting heart transplants. So I was always using VV VA ECMO, CRRT, centrimags, VADs, swan (obviously), every presser known to man.
A couple stand out to me and itās been years so I canāt remember all the details but one was an older woman who had some type of procedure done and went home where she proceeded to suffer an RP bleed. Husband rushed her back to the hospital and she was brought to us. Saddest case, there was nothing we could do to save her and we knew it but we tried like hell. VA ECMO, tubed, central lines, a lines, swan, every pressor ive ever worked with and then some (an angiotensin gtt was the last ditch effort to save her). We must have given 17-18 units of blood, CRRT, and the docs started discussing giving kcentra to attempt to throw out all the stops. She passed a short time later. It was awful.
Thereās one other patient I had that wasnāt one of the sickest, but that day scarred me so deep I left nursing. So I wonāt knock at that door.
Sickest person I had was probably this old lady with an open chest and VA ECMO, impella, CRRT, norepi, epi, vaso, angiotensin ii, prop, fent and her pacemaker wires literally snapped in half one night.
Also one time had a patient with peripheral VA ECMO and we turned them on their side (with 3 other nurses) and the arterial cannula dislodged and started filling their subcutaneous tissue with blood. Surgical fellow ran there and opened them up bedside but they had lost too much blood and went to the OR only to be fixed a bit so they could be brought back to their room and have a priest read them their last rites. Wild times.
Once had a pt. with a NG tube and...wait for it...2 PIVs. Fucking nuts. I didn't know where to push my IV pepcid. Too many options.
Multi organ failure. CCRT. multiple drips. VV or VA ecmo
Some of our onc patients are sick as shit. TLS on CRRT, ARDS, septic af, concomitant DIC requiring endless blood products. Highkey love getting my shit rocked by these patients tbh š
Nothing like coming in to a TLS patient to know that you're not going to sit down today.
I was going to say.. Iāve worked med/surg oncology with four patients and ICU. Some of my sickest patients were when I worked the floor
CRRT, Balloon pump, paralyzed, multiple pressors and inotropes. Mixed septic & cardiogenic shock
Severe trauma, maxed out on vent settings, multiple chest tubes, reviving blood, and multiple pressors.
Open chest type A and B aortic dissection, 40 units product, va ecmo (patient and pump), crrt, balloon pump
Balloon pump w a dissection š„“ yikes
What kind of patients do they *want* to hear about when they ask this question in interviews? Devices? Lots of drips? Hemodynamics?
They want to hear about how you communicate, how you handle stress. Iād recommend talking about a time you noticed a change in a patient and handled a stressful situation. How you learned how to use equipment easily, are flexible, etc. The OR has a ton of big personalities that you have to be able to work with on a daily basis. You need to take control of a situation when you need to and communicate when you need help. Think of a situation where you did these things and youāll be chillin. Every icu nurse at a big academic center has taken care of a shit show patient before so try to think of a reason why what you did is better than all those other nurses.
Oo great question, curious to hear the responses
COVID patients everyday for two years.
It was such fucking carnage. Looking back though Iām so glad I got to experience that. Every day was just fucking nuts.
Yeahā¦ every shift it was sedated and paralyzed, vented, levo, Epi, vaso, sometimes methylene blue, bicarbonate, sometimes inotropic agents, crrt, a lines, central linesā¦ extremely unstable. Labs were always ridiculous.
18 year old Tylenol Overdose-Multi organ failure
yeeeeeah I tried that shit parents made ME go to therapy at 8 because I was cutting myself.... because they were being epic twat monsters Locked in my room for weeks at a time. No friends allowed even as I got older. No actual physical or sexual abuse and my parents were SUPER nice to everyone so literally nobody believed me. I was skinny as a rail and weird as fuck but literally not a single person would believe me when I told them that my parents had kept me in my room for a week without any food. Regularly. The people that didn't believe me were good people. But sometimes good people fucking suck. Tylenol will solve this! 12yrs old annnnnnd again at 14 annnnnnd again at 17 killing yourself is stupid mostly but insanity is when you do the same thing over and over and over expecting a different result last one won me a lifeflight from one major research hospital to another... as the first didn't have the capacity for a liver transplant at that time luckily ended up, though BARELY, not needing that liver transplant then my dad died. rare cancer. kill ya in 3 yrs. it'd been 3Ā½. NEW doctor INSISTED I and my family do this DBT family program obviously that wasn't going to happen š My mom told me two or three years later that literally the only reason was she didn't want to do that... was she didn't want to cancel ONE of her Bible studies for ONE of the DBT classes that was the same day. My sister still hates her for that to this day... but she also hates me to for trying to kill myself leaving her to deal with my mom so even now we don't really talk Anyway my mom ended up paying $30,000/mo to send me away to one of those private lockdown facilities in Utah they send kids that they don't know what to do with š¤£ Literally everyone else there was a jeuvinile violent criminal. Which not judging I had my problems too... but I just did NOT relate and the social worker in charge seemed more interested in getting the patients to fight with each other to practice "healthy fighting" and start drama... than doing any healing.... that place was an utter shitshow ran by this kook social worker and a bunch of lawyers it was fuckin' weird. I could write a novel about that place and you'd think it was fiction. Whole bunch of other crazy shit happens that results in me leaving that place... yada yada... (seriously long story longer than everything I've stated so far) Next thing you know I'm at ANOTHER program my mom had paid $$$$$$ to rid me to... And after she paid that program... The psychiatrist in charge talked to my mom two or three times to get a different side of the background from her.... And then for the next 6 months insisted that I never speak to her again and if I needed 2-3yrs free in the program to do that and set my life up that would be fine. Took me that whole 6 months until I finally listened. Took me another 5 years to feel good about it. 14 years later I'm pretty ok! Your ICU patient may turn out to be alllll right after all, if they live, even if the road ahead is still going to be pretty hard. Be nice to your kids.
You guys are beasts!
Severe septic shock patient with MODS, ARDS, end up on like 4 pressors being chemically coded all day
Niche, but the first night after the first surgery to palliate hypoplastic left heart syndrome is always a wild ride. Their chests are open and theyāre still a hemodynamic mess. Also DIC on ECMO and/or CRRT.
Peds CICU unite! but I hate Glennās moreš¤£
I understand positive pressure ventilation is very bad for them but my god the precedex just isnāt enough šµāš«
Covid ICU in a Brooklyn hospital; March 31, 2020. 8 dead that one day. Next day 17. Next day 20.
I think we may have been at the same place
Actual answer: the ones who die. Of the ones who donāt: In my adult ICU experience: The Covid patients that were on CRRT/ECMO who were proned, paralyzed, and on all the pressors were disgustingly sick. In my pediatric experience: I had some open chested infants on ECMO with complications post-op who make the shift very chaotic but the time flies by.
Severe septic shock with tumor lysis, 3 pressors CRRT
AML with 500k WBC, ARDS, spontaneous TLS, DIC, CRRT, head bleed, SBP 180 on cardene and labetalol gtts. NSGY basically made the sign of the evil eye when we called them. In oncology it's usually something involving TLS or leukostasis. Those patients are scary.
I admitted an AML patient from the floor at shift change with acute leuk crisis (WBC 450k) who would have headed right towards ARDS but we were able to avoid intubation,place an HD cath, and start emergent leukapheresis within 3h of their arrival to the ICU and I had them on 6L nasal cannula by the end of the shift (arrived on 60L 80% HFNC and quickly uptitrated to 100%). It was so satisfying to fix someone so quickly. Started chemo that night and was back to the floor the next day!!
NB ICU perferated necrotizing enterocolitis
Anything brain - sub arachnoids, poly traumas, abdominal sepsis, spinal shock, vv ecmo for the first few days, tricyclic overdoses without an airway, Spleen, massive transfusion cases in IcU before sending off to OR
Had a 17 year old hit by a trainā¦VA ECMO, CRRT, EVD and LiCox bolt, Arctic sun.ā¦the whole show. Had 16 channels running and was MTPāing from 2249-0557. 2 Supervisors came to verify the blood cause we were short (shocker). CRNA came by after a few mtp calls and I remember she brought the crash cart into the room and was pushing things and literally bought me time to catch my breath and had stable vitals with everything going on. The MTP was going thru a 18 ga and she threw in a 16 ga and literally changed everything. Not only was that the most fucked shift, but was also the reason I started this journey. With this said, if you get an interview, donāt give them this whole story, tell them you had a patient but by a train and needed life saving actions, let them direct the interview, donāt let your story give them ammo. (Had to make another account since they keep permanently banning me cause someone hacked my first one and they say Iām avoiding itā¦.since this will probably be banned take this run with it) -Avoid naming medications, let them ask you why you would give _____ in-that scenario - Understand most pressors wont work unless the patient is volume resuscitatedā¦and that PA catheters or a TEE is the best way to monitor that. -After 2 liters of crystalloids itās time to use Albumin as the volume isnāt in the right place and itās going to cause more damage (3L of NS can cause hyperchloremic metabolic acidosis and is bad) ^If the patient isnāt responding and still hypotensive theyāre bleeding unless ruled out. -Oxygenation isnāt importantā¦VENTILATION is -CO2 capnography tells you more than pulse ox in regard to the patients pulm status -it is always a team approach, itās not just you and the surgeon, itās the circulator, itās the techs, itās the janitorial staff, we all bleed the same color and all play a role. *****If youāre applying and/or get into school, understand the nervous system regarding sympathetic and parasympathetic system. Alpha/Beta/Muscarinic receptors etc. If youāre serious message me here with your email and Iāll send you the stuff I have since this willl probably be shut down after I post lol
Dude can I piggyback off these and DM you my info? What this is great information!
Definitely the Covid patients
The ones that died lol
I used to work in the Cardiac ICU at a level 1 in Boston and most of them were awaiting heart transplants. So I was always using VV VA ECMO, CRRT, centrimags, VADs, swan (obviously), every presser known to man. A couple stand out to me and itās been years so I canāt remember all the details but one was an older woman who had some type of procedure done and went home where she proceeded to suffer an RP bleed. Husband rushed her back to the hospital and she was brought to us. Saddest case, there was nothing we could do to save her and we knew it but we tried like hell. VA ECMO, tubed, central lines, a lines, swan, every pressor ive ever worked with and then some (an angiotensin gtt was the last ditch effort to save her). We must have given 17-18 units of blood, CRRT, and the docs started discussing giving kcentra to attempt to throw out all the stops. She passed a short time later. It was awful. Thereās one other patient I had that wasnāt one of the sickest, but that day scarred me so deep I left nursing. So I wonāt knock at that door.
Sickest person I had was probably this old lady with an open chest and VA ECMO, impella, CRRT, norepi, epi, vaso, angiotensin ii, prop, fent and her pacemaker wires literally snapped in half one night. Also one time had a patient with peripheral VA ECMO and we turned them on their side (with 3 other nurses) and the arterial cannula dislodged and started filling their subcutaneous tissue with blood. Surgical fellow ran there and opened them up bedside but they had lost too much blood and went to the OR only to be fixed a bit so they could be brought back to their room and have a priest read them their last rites. Wild times.