Milk of Amnesia

I am currently doing a rotation in pediatric sedation. It is awesome. Every day I put kids to sleep and wake them up again. I watch them breath, I tilt their heads, thrust their jaws, blow by oxygen as needed and see procedures I have only read about before…kidney biopsies, intrathecal methotrexate therapy, etc.

I have done propofol sedation before in the emergency department, but now I am working with a service dedicated to sedation. Two full time nurses & 7 pediatric intensivists rotating on a call schedule…just to sedate kids for any procedure that comes up. Some are scheduled ahead and some are done same-day.

Today was the coolest day so far. The director of the PICU paged me about 4:30 for a 7 year old, 1 day post-op mitral valve repair who needed a chest tube. I have never worked with the charge nurse in the heart rooom of our PICU before, and like many ICU charge nurses (no offense here…) she is IN CHARGE. The bed is placed in the room just right, the tubes are perfect, the adjustments of every knob precisely calculated. I moved the patient’s bed about 6 inches to rotate the head away from teh wall. “What your doing with the bed?” she scolded. “I’m moving it so I can access her airway,” I replied. Clearly not an adequate answer for her, as she told me that the bed was already adjusted so they could get to the head.

I bet she’s never been the one doing the intubation in an ICU bed surrounded by tangles of wires, hoses, meds & tubes. That’s not the time you want to discover that the bed’s in an awkward position. If I’m managing the airway, I am positioning the bed.

So besides the charge nurse I have to deal with, there is the cardiothoracic surgeon. As soon as I introduced myself to the patient’s nurse (not the charge nurse) and told her I would be doing the sedation, her first response was, “Not with Dr. CV Surg, you’re not!” She painted a picture of him as an ogre who would turn me into stone if I tried to touch his patient. I was a little nervous, but proceed to prep for the sedation like all the others I’ve done this past 2 weeks.

As a student nurse drew up the propofol, I began programming the infusion pump. “I don’t know who you are,” the charge nurse stated to me nose to nose. In other words, “You’re not going to do one more damn thing in my ICU until I know what your training is.” OK, fair enough. The fact that the PICU DIRECTOR was precepting me on the sedation service for the past 2 weeks was inconsequential to her.

I finally have the meds drawn, proper tubing found, pump programmed, anesthesia mask ready if needed, suction at the bedside. I begin the sedation prior to the arrival of the cardiothoracic surgeon. I figure if she’s already asleep when he arrives, he won’t have a chance to yell at me.

Just as he arrives, she is nicely sleepy. He gives local lidocaine and she squirms away. Just a touch more of milk of amnesia brings her back down. Her blood pressure is into the 70s, so I back off on the infusion rate. He continues his procedure and the stimulation brings her pressure back up. She begins to mumble. I increase the rate again. He finishes the chest tube and I lower the rate again. He takes advantage of her persistent sleep to remove the mediastinal drainage tube. By this time, the propofol is off, and she wakes up smiling. It was perfect, like a dance between myself, the patient and the surgeon. Everyone was happy, I even got bedside teaching on furman tube placement by both the intensivist & the surgeon while simultaneously holding a chin tilt, securing her right wrist, adjusting the infusion and delivering boluses of medicine. I’m starting to feel more comfortable with this sedation stuff.

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