Open Heart

For a majority of my nursing career, I have been primarily involved with cardiac patients on a step down telemetry unit.
After you have recovered enough from open heart surgery to leave the intensive care unit, you come to us, where we make you get your sore self out of bed, walk down the hall on legs that have usually had part of their circulation stripped from them, deep breathe and cough from a chest that has had its bones sawn (is that a word?)open and pulled apart, then wired back together with something that looks suspiciously like chicken wire, and generally torture you in ways that will make you SO ready to go home! We remind you in very somber tones and with serious faces what will befall you, should you NOT do exactly what we tell you. We hand you this cute little heart shaped pillow when we make you cough and move, and we tell you to give yourself a hug. Open heart is not for wimps, but most people survive it and go on to live more normal lives, quality lives, for years to come. Some become cardiac invalids, we describe many of these as people who are "enjoying their poor health". Some quite literally kill themselves by not doing their share to recover.
Recently took care of a patient who had come back in with a sternal abscess 7 months post op. Kind of unusual, we generally see them come back in much earlier with infections. Others who had seen him before they took him back in to "clean" him out said his chest looked like an alien should be jumping out of his chest at any given moment.
When these infections occur, they have to remove part or all of the sternum, and for a while, we do what is called "wet to dry" dressing changes. This involves packing the wound with sterile normal saline moistened rolled gauze. You have to have timing and a certain "touch" to do this, as the chest wall is moving with the patient's breathing, and the ribs move away from, and towards each other with each one. You want to gently pack the wound so it touches all exposed surfaces, without putting too much pressure on the heart and lungs that are now pretty much RIGHT THERE! Everyone watches the heart beating for a few seconds before they repack, just because they can. You also have to have timing, because the ribs will pinch your fingers as you pack the dressing in, and bones are hard! You evaluate the drainage while you are doing this dressing change for purulent drainage, oozing of blood into the wound, and the quality of the tissues at the wound bases.This dressing debrides the wound, removing dead tissue and nasty drainage . After the infection is under control, surgeons with go back in and crate a "flap" to protect the heart and lungs and generally stabilize the chest wall again. Not a good situation, many patients don't survive long after they have gotten a sternal infection, and they go through an awful lot before the end comes.
Changed this patient's dressing, wound looked good, tucked him into bed for the night......an hour later, one of my coworkers heard a noise in the room , walked in and found him covered in blood, and yelled for me. When I went in the room, he was sitting at the side of the bed with his hand on an IV site in his neck that might have been the source of the blood if he pulled it out, as it was in a pretty good sized vessel. But, he had a lap FULL of blood, the side of the bed was covered, and a puddle the size of a large pizza was on the floor beneath him. The dressing on his chest was swollen with a huge blood clot, and the blood was still coming. I called a CAT team call and began directing my babies, all with eyes the size of dinner plates. We held pressure, got more dressing material and got him moved to the unit in record time. Not once did they falter, not once did they fumble, looking for what we needed. Like a well oiled machine, each one did what they were told, ignoring their racing hearts and brains and attending to the task at hand.
We got him to the unit with a very cute tiny nurse straddling him and pressing on this chest that had no sternum to protect his heart and lungs from the edges of his rib bones. The surgeon was called in, the open heart team was called in, four units of blood and two platelets was ordered, and the family was called and informed that their loved one was in big trouble and was going back to surgery. For two hours this tiny nurse held pressure on his chest while everyone involved watched closely, both patient and monitors, for the changes that could happen any second from the massive blood loss.
The surgeon told me that he thought the patient had torn his right ventricle, as they had found parts of the sternum adhered to the heart when they went back in to clean the infection. He very plainly told me "He's not going to survive this". HMMMMMM. But, you have to try.
Wife is coming from a little town far enough away she won't make it there before the patient goes to surgery, but it can't be helped, if we wait for her he dies, if we don't wait for her, he probably still dies. But, we had to try. I go back into the room and ask the patient how he managed to get a bunch of good looking women in the bed with him like that, he grins and says, "I'm not sure". Still somewhat with it, but he's beginning to pick "ticks" off the tiny nurse's arm, even tho she keeps telling him they are freckles.
Nothing for me to do now, I have turned him over to the crew who will help get him to the OR. All we can do now is see what happens. I go in the hall, and the patient's daughter is running down the hall. I stop her, take her to the waiting room, and get the surgeon. He gently tells her the truth about her Dad's chances, and she goes in to see him. She holds up very well, then comes back into the hallway and sobs uncontrollably in my arms. I call the chaplain to sit with her until her Mother can get there, and call security to keep an eye out for the Mom.
Then, I go back upstairs to my floor, where my babies have been holding the fort for over an hour. And we wait.
This surgery could be over in a matter of minutes, with the terrible expected outcome, or it could be many hours, and still with a terrible outcome, OR there can be a wonderful mixture of skill and miracle.....we hope.
An hour later, we get the phone call. Patient will be out of surgery in a few minutes, he had torn a major blood vessel, NOT the ventricle, and our holding pressure on his poor, unprotected chest wall saved his life!! My babies, not faltering, not fumbling, have been a team that got this guy safely where he needed to get to live! WE DID THAT!! Not by following a bunch of orders a doctor gave us, but by knowing what to do, when, and doing it! WE did it!
I couldn't have been prouder. We couldn't have been more pumped! I have gotten over the need for the adrenaline rushes that this job provides, I leave that to the new babes who secretly wish for it, while not wanting to wish bad stuff on our patients. When we have a code, unless it's my own patient, when the room has filled with the usual 30 people, all in each other's way, I go to care for the other 20 something patients they have forgotten are still out there. I let them have the excitement. But, this was something entirely different. Something none of us will forget, and will be a story we tell for the rest of our lives. We did it.
Experience, not including myself? Still less than a year. Competency? Quantity beyond sufficient.
Next time you are in the hospital and you ask that fresh faced nurse how long he/she has been a nurse and they say "Six months", don't fret. If they are part of the right team, it will be just fine.