Cardiac Intensive Care - Hospital Placement Reviews

Week four of hospital placements was based in a Cardiothoracics centre for my intensive care sign off.  The Cardiothoracics centre is important to me to understand as if I have a patient with a stemi that meets required criteria, I would likely be bringing them to this centre as there are only two PPCI centres in my area.

Background
I was required to be on this placement for three days, for 13 hour shifts.The centre is for planned procedures and emergency cases, whilst also having a really large ward for patients varying in severity from 'ready to go home' to high dependency. I was based in the high dependency part of the ward with the opportunity to end up in different departments throughout the centre, such as the waiting rooms, operating theatres and intensive care.

Day 1
With another long day ahead of me, I woke up at 5am, left the house at 5.30am and arrived just before 7am. I went in and found the nurse in charge who directed me to get changed, and then to the staff room. Handover happens in the staff room at 7.30am which different sections of the huge ward discuss their patients with nurses and healthcare assistants. A walk-around then occurs where the nurse hands her patients over to the next nurse. I walked around this, and then went into the doctors handover where they discuss patient's conditions and next steps. This whole time, I hardly knew what was going on but I did take notes on my handover sheet. There are a lot of abbreviations and conditions and procedures I knew nothing about which is fine because I am a paramedic, not a cardiac specialist.

I ended up with the lady in charge of the PPCI phone. If you are not aware, ambulance crews call the PPCI centre if their patient meets the criteria for PPCI. They also fax across the ECG so it can be checked by the staff. A lot of patients do not actually meet the criteria, but paramedics call anyway. The nurse in charge of this says she finds it frustrating as some paramedics basically pass the buck to the nurse to determine whether or not they need to go. She said she likes it when the paramedic calls and says 'I am bringing you this patient because ... here is the ECG, see you in 30' rather than 'can you check this for me, I am not sure'.

It was a slow morning on the ward so the nurse showed me into the education room to read through their procedures, and she told me she would come and get me if anything went on. Huge mistake. I gave it an hour and then got bored, I ventured onto the other parts of the ward and had a chat with the other nurses. I then went onto my lunch break for 30 minutes. I came back, determined to not end up in that room anymore as I was not learning anything in there. I went and spoke to this lovely nurse who, when she had a chance, went through ECGs with me and we spoke about different patients conditions.

Then a patient who had a ROSC came into PPCI. HEMS had travelled in by ambulance, so I met them at the door and came upstairs with them. The patient went straight into PPCI after suffering a witnessed sudden collapse with bystander CPR. The patient was intubated and sedated. I was able to wear the metal protective jacket which stops the x-rays damaging the body, and I spoke to the paramedic crew who also had a non-university student with them as they were able to watch too. My advice is to talk to the radiographer who can explain everything that is happening, as unless you are very knowledgeable in this area, it will just look like a tree lights up on the screen every so often (just being real with you).

I then followed the patient upstairs to intensive care where I was able to watch them transfer him onto their life support and discuss what will happen next with him. I watched them take bloods, catheterise and hook him up to all kinds of machines. Which I was up there, half the intensive care ward had been turned into an operating theatre as a patient went into cardiac arrest on the ward and he was too unstable to move into theatres so they conducted some kind of major heart surgery (where the patient's heart was stopped and blood was circulating through a machine) and they had been going for 10 hours, not in an operating room. The life-saving treatment that this centre offers is absolutely incredible.

This wrapped my day up. Ready for my long journey home and a good nights sleep!

Day 2
Another dawn, another day on placement. Again, I came in, got changed and went to the handover room. Today it was planned that I was to go into the planned procedure operating theatres, however this did not happen as all elective surgeries were cancelled due to problems with equipment. This meant I was able to go into the waiting area for other planned stents, so I went and got changed into scrubs. I was able to cannulate patients, take obs and fill out paperwork. The cannulas they use in PPCI are different to the ones we use on the ambulance. They do not have the filter at the back which stops blood coming out, and I through habit always take the white cap off the back so I do not lose it when I withdraw the needle. This meant as soon as the needle was in, blood came out... Everywhere. These patients are also on a load of blood thinners so thin blood literally poured everywhere... on the bed, her gown and the floor. After a fumble I got the cap on and luckily the patient was really nice so it was fine, we had a laugh and she went and got changed into a new gown. The next cannula I did, I did not take the cap off and it was a lot less messy.

I was able to watch more stenting in the cath labs today, and I was also part of a controlled trial which I am not allowed to talk about. Luckily I really did not understand what was going on (okay I understood a little but not enough to be able to explain it) so I was a pretty safe subject to be in there. At the end of the day I ended up back in my area of the ward and was able to sit and talk to the education lead who was so lovely and sat down and went through a load of ECGs with me and printed them off and gave me a load of tips. He was such a babe!

Day 3
Today was slightly less interesting. I did not go into surgeries, however I did cannulate a patient (that no one else could get a cannula in woo!), and it was nice to have a less stressful day. We had some really dependant patients on the ward, one of which was GCS 3. There were difficult conversations about turning off life support which the other nurses, and the patient had a really complicated living situation so it definitely did not sound easy. I am glad that the decision is not mine to make! We provided observation for a few patients who required continuous monitoring. I was able to go over ECGs with a fellow student and discuss patient care. Really excitingly, the patient who I met on the first day came down from intensive care! He was able to get up, have a shower and completely care for himself! This was an amazing moment as he had been upstairs (in intensive care) for three days and had made a very quick and successful improvement. It really emphasised how amazing the staff in the PPCI centre are, and how they save and change lives.

The patient who was GCS 3 was in a very similar position to the man I met on the first day. Both were similar age, lifestyle, had a witnessed arrest with bystander CPR and had a ROSC and had PPCI. Both very similar in situation and yet they were so far from each other.

Conclusion
Firstly I would like to emphasise the situation on the third day where two very similar patients had very different outcomes. I want you to remember this when you have a cardiac arrest that goes badly. ROSCs are rare, and please do not believe that because the patient did not come back, that it was your fault. When a patient is in cardiac arrest, they are dead. So long as you are providing high quality BLS and progressing to ALS and possibly using other resources is applicable, you are doing everything you can and this is important to remember. Please do not blame yourself.

This was a great placement, it was really informative and most of the staff were amazing. Ask questions and get as involved as possible (and this includes providing some personal care under observation if required) as then the staff will be more inclined to help you. The education lead openly said to me that he will only help those who show a proper interest. Get involved, watch as much as you can and do not let them shut you in the education room. That was a huge waste of time. This placement was great for me to improve my patient care, discuss the possible pathways with patients and learn a whole load about ECGs. It was a truely valuable week on placement.

Finally: scrubs are really comfortable to wear!

Read the others in this Hospital Placement series!
Acute Medical Unit
Maternity
Community Mental Health Placement - Prosthetics
Cardiac Intensive Care
Paediatrics


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