My Placement Experience at Critical Care ARI.

Hello folks so my second, second year placement was located at Critical care unit at Aberdeen Royal Infirmary. I am extremely honoured to have had a placement here.

About Critical Care

Since covid Critical care Unit includes ICU (ward 201) and High Dependency (106 b). There are 16 beds in 201 and 14 beds in 106. The critical care ward cares for ‘level 3 patients’ (those who have multi-organ failure) and ‘level two patients’ (those who have single organ failure). Patients can be admitted from all wards within NHS Grampian, A & E, theatre, RACH, AMH. And other hospitals across the Grampian, highlight, Shetland, and Orkney region. Cardiac intensive care cases are cared for in the cardiac intensive care area on ward 201.

What does an every day looked like in critical care and skills and learning obtained.

Everyday was different, I had an opportunity to visit 201 and 106 b over the 5 week placement. I would find out just before my shift via What-app which ward my shift would be so it was a surprise to find out where I would be working. The shift (day or night) started by a team handover and then we were allocated to care for 1, sometimes 2 people and would then go to the bedside to receive a hand over for that person. I came across a wide range of conditions from sepsis, to trauma incidents, to head injury, to heart conditions (cardiac arrest), type 1 and 2 diabetes, post surgery patients, liver conditions, acute kidney injury, overdoses, gastrointestinal conditions and many respiratory conditions. I also had the opportunity to observe the work of a Apheresis nurse (blood and platelet transfusion ) which was required to treat a blood condition called TTP (Thrombotic Thrombocytopenic Purpura) this treatment was absolutely incredible.

At the start of each shift we would do a head to toe examination so this involved putting the ABCDE approach into practice which we learnt in the nursing module this year so that was great. I was really excited about putting this knowledge into practice. I found the chest auscultation and neurological pupil dilation examination most fascinating. I then had the opportunity to write the patients care notes on the online system.

We would then prepare and administer any medications throughout the day and carry out hourly observations which included measure fluid output via the catheter. I had the opportunity to change the nasogastric feed via the pumps which I now feel confident with. The patients required turned every so often which involved the use of efficient manual handling technique and the use of the glide sheet. Much of the work involved cluster care. Many of the people on this ward did not require oral food from the trolley because they were intubated. I had the opportunity to observe the intubation process a few times.

I have had much experience during this placement with blood gases which was fantastic and in fact I took it upon myself to create a presentation about blood gases. Blood gases can provide so much information about a persons state. The blood gas is taken via a arterial line. I had the opportunity to observe admissions whether that be from a & e, another ward or the road or air ambulance it was great to see as each admission was so different. I had the opportunity in these instances to help get the patients settled into the ward by hooking all the leads up for ECG and observations.

Blood gas

I had a lot of opportunity to perform suctioning both invasive and non invasive for the patients who were intubated. I had he opportunity to help prepare some medications with my supervisor and make up IV’s with her observation of course. This familiarised me to some of the medications that are most commonly used on this ward (you can see a list at the bottom of this blog post). I had a chance to learn about the cardiac machines and ventilators. One new thing I learnt about in terms of the cardiac monitor was MAP score (mean arterial pressure) and it should be 65 > . This was picked up via an invasive means via the artery. What was interesting about the observations were that text book numbers were not really seen on this ward so it was normal to see tachycardia, bradycardia , hypertension hypotension as this was typical of many of the patients conditions and why they were on this ward being monitored and treated closely. I observed a bronchoscopy which was really interesting. I learnt a bit about ECMO which was also very interesting and very complicated (I take my hat of to the nursing staff trained to use ECMO). I observed kidney filtration a lot which was very interesting.

I learnt about ICP monitoring which measures the pressure in the brain blood, and cerebrospinal fluid against the skull. This can be used by patients who have sustained a head injury. It can be monitored via the monitoring system.

The care was mainly one to one care because the patients on these wards were critically unwell and often received ventilation treatment. There were occasions that I cared for ward level patients and sometimes I was given the opportunity to care for them independently (with a nurse near by when required of course) this really boosted my confidence.

I had the opportunity to practice my first venepuncture and cannulation. My first venipuncture was very successful my second was a little trickier but I will just keep going! My first cannulation was not as successful as I had hoped it would be, I got a partial flush back so that is one skill I need to keep practicing! 🙂 The main thing is to try not and get disheartened if a skill doesn’t go as planned!

Sadly I did experience the death during this placement and was involved in my first few last offices. Although it was sad, I was not as upset as I thought I would be during my first last offices (this surprised me a lot). I wondered if this was because they were not people that I had worked with and built a rapport with. I wonder if last offices would have hit me more in the feels if I had worked with these people. I felt I was very professional during last offices and it was important to me to be respectful at all times, by still talking to the person and telling them what was happening just like I would when they were alive. It was interesting to see how last offices was carried out by different staff members.

I had a vast amount of learning, there is so much more I could share but I would be here forever typing. I didn’t realise how much learning I had had until now just by reflecting on this experience.

After a nightshift

Extra opportunities

Hyperbaric unit – So I had the opportunity to visit the hyperbaric unit during my placement. I was taken into the chamber for a look which was really cool! I did not expect it to be quite as big as it was! There is only one way in and thats through a small hole at the end of the chamber. This is the only NHS hyperbaric chamber in the UK. They treat elective patients and emergency dives. The can also treat ventilated patients in the chamber.

What is Hyperbaric oxygen? It is a high-pressure oxygen type therapy used to speed up the healing of carbon monoxide poisoning, gangrene (a condition where there is a loss of blood supply to tissue), stubborn wounds and infections and the bends (decompression illness). The treatment involves breathing pure oxygen in a pressurised environment. Within the chamber the air pressure is increased two to three times higher than normal air pressure which allow the lungs to gather more oxygen than within normal air pressure. This allows the blood to carry this extra oxygen through the body to help fight bacteria and stimulate substances that will promote healing. The patients puts a hood on within the chamber. There can be no electrical devices or jewellery in the chamber. There is a designated specialist nurse who will go into the chamber with the person receiving the treatment. People who enter the chamber must wear anti-static clothing as static and O2 could cause a fire.

I was so surprised to learn that sometimes the person receiving the treatment and the nurses can be in the chamber from anything from a few hours to 4 days straight! There are beds and a bathroom type area. There is also a wee hole that can be used to pass food through.The chamber pressure is operated via the control room which you can see from the pictures below. It was incredible to visit! Thank you to Abbie Taylor who gave me the tour!

Research and Follow up team– I had some time to learn what the follow up and research team do. So during this time I had a little induction into tracheotomy care. I also learnt about the audit system and various research that is ongoing just now, which was really interesting. I also had the opportunity to observe the follow up process which involves communicating with patients who have recently been discharged from intensive care (been intubated etc). I was invited to join a follow up appointment which was very interesting. I was very interested to hear about the patients experiences during their time in intensive care. This fascinated me! Many patients were said to have had hallucinations, bad dreams and found it quite a scary experience.The research behind this is incredible!

CICU/theatre – I had the opportunity to follow a patient through to theatre for an aortic valve replacement which was incredible to observe and once this procedure was finished I observed post surgery care. A chest drain was inserted to prevent cardiac tamponade in the chest which could restrict cardiac movement. I learnt that there are different types of values that can be used in this procedure which very much depends on the individual. There is mechanical values which tend to be used with younger patients and tissue values that tend to be used for older patients. It was a bovine tricuspid value that I observed being replaced. I watched as the old value was removed and then new one was replaced. It was a very intrinsic procedure as it had to be sewed in through little tiny holes. A heart- lung machine was used by the perfusionist to take over the function of the hearts pumping action and oxygen transportation into the blood. That was incredible!

Aortic Valve

A heart lung machine

Common medications seen in critical care

Alfentanil

Metaraminol

Remifentanil

Propofol

Noradrenaline

Adrenaline

Furosemide

Round up:

Overall I really enjoyed this placement experience, and I am so honoured to have had the experience. However one thing I did miss was interaction with patients because most of the patients were sedated. Saying that there was a lot of interaction with family so family centred care was just as important as person centred care in this placement.

I have to say that the staff on this ward are absolutely incredible. Their work is pristine! I take my hat of to every single one of them for the amazing life saving work they do! Thank you all so much for a fantastic learning experience! A really big thanks to my assessor and Supervisor for all their teaching and support! 🙂

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