ReflectiveJournaling

Name:____JamieSteele____Date:__3/1/2017_______

Noticing
Subjectiveandobjectivedata:
PatientwasoriginallyclassmateKellyspatient,hewasdeemedtobeaSTEMIpatientandwas
broughtovertoApod(thecriticalcarepod),westartedfollowingSTEMIprotocolwhichtheytermasa
DASH.WhichincludesplacingthepatientonoxygenwhichhealreadywasbuthewasonaNRBonas
highaswecouldflowoxygenandwasonlysattinginthehigh70sandlow80s.Togivethepatient325
ofaspirin,5,000unitsofheparin,Zofransublingual,the3ofnitroifnotalreadygiven,morphine,
brilenta,etc.Therespiratorytherapistcameinthepatientsroomandplacedthemonhighflow/optiflow
oxygenwhichforcesahigheramountofoxygensimilartocpapandthisimprovedthepatientsoxygen
saturationstothelow90s.Uponexaminationofthispatienthewasslightlyconfused,coolandclammy
skin,respiratoryratehighandpale.Hedidnotlookgoodandwasnotstable.Thecardiologistcamedown
toassesshimbeforewetookhimtocathlabandsaidhewantedthispatientintubatedbeforegoing
upstairs.SothephysiciancameinwithpharmacytodoanRSI,theygavethesuccinylcholineand
etomidatetosedateandparalyzethispatientandintubatedhimwithan8.5ETtubeusingaglydescope.
Onceintubatedhewasstartedonpropofoltomaintainsedation.Whenhewasintubatedhisheartrated
droppedintothehigh40sandlow50sforafewminutesandwewereworriedwhenwewenttoaddress
itwiththephysicianhisheartratejumpedintothe100sandhewasinafibandhadperiodswherehis
rhythmlookedasthoughhewastryingtogointoSVT.WhenhisHRwasinthe4050sweplacedpads
onhimandturnedthedefibrillatortomonitorasaprecautionsincewedidnotlikewhatwewereseeing.
Thispatientwastakentothecathlabshortlyafterthis.
Howdidyouknowtherewasaproblem?Abnormalpatientpresentationoryourgutfeeling?
Therewasaproblem,thispatientwasinApodthecriticalcarepod,anditwasntamanicMondaywhere
theyopenitlikearegularpod.Patientwasonoptiflowandbarelymaintainingasatinthehigh70slow
8s,thatbipapimprovedpatientso2saturation.Thepatientslead2wasshowingSTelevation.
Interpreting
WhatotherinformationdoIneedtomakeadecision?
IfeltwiththispatienttomakeadecisionthatthispatientiscriticalIfeltallIneededwasonelookatthis
patienttoknow,butthatthevitalsignsandlabworkwereshowingthispatientwasonesickpatient.
IsthereanyoneelseIneedtoinvolveornotify?
Pharmacysinceintubationpotential,respiratorySatsnotmaintainedmayanddidneedbipapandended
uponvent.Providerneedstobepresent,thispatientissickandneedsadoctortoevaluatehimagain,and
hehasdecompensatedandmovedfromaregularpodtoacriticalcarepod.
Whatcouldbehappeningandhowcriticalisthissituation?
Patientdecompensating,couldbeseptic,havingaSTEMI,ARDS,manythingscouldandweregoingon.
ThissituationisverycriticalwestoodthereandwatchedhimandhisrhythmtryingtoconvertintoV
tachandwecouldnotfeelapulsewhenthiswouldhappenthispatientlookedlikehewasabouttocode.
Responding
ShouldIdosomethingnoworwaitandwatch?
Dosomethingnow!
HowwillIknowifIammakingthebestdecision?
Thispatientdoesnotlookgood,worstthingisthatthepatientgetsreevaluatedbyproviderfornothing,
bestthingpossiblethispatientslifecouldbesaved.
WhatinterventionscanIdelegatetoothermembersofthehealthcareteam?
IVaccess,placingpatientonmonitor,drawingoflabsandcultures.Candelegatepharmacytopulland
drawupmedications.
Reflecting
DidImaketherightdecision?
Yes.
DidIachievethedesiredoutcome?
Yes.
WhatdidIdoreallywell?WhatcouldIhavedonebetter?

IfeltIwasapplyingtheinformationverywellinwhatIhadseenandlearnedinschoolthusfar.
Applicationofwhatatypicalpatientwouldlooklikewhowasnormalandwhatatypicaldashpatient
lookedlikehelpedinidentifyingthispatientwascritical.Thoughhowtheylookdoesntalwaysmean
everythingIhavelearned,youcanhaveacriticalpatientwhoisA&Ox3andhasamajorbleedor
somethingelse.WhatIcouldhavedonebetterwasgetmoreinvolvedincare.Theteamworksso
efficientlytherethatifyoudonotjumpinandassignyourselfsomethingyouwillendupstandingthere
watchingthemworkonthispatient.